The Frozen Consequences
The State of Canadian Aviation Investigations, Part 3: Moshansky and the Dryden Commission
This is Part 3 of my series “The State of Canadian Aviation Investigations”. Click here for Part 2, which goes through nearly the entire saga of the CASB.
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Prologue
March 1989. It has been a few months since the Arrow Air reports have been released, and everyone is furious. The Board Members that supported the investigators’ findings are furious that the government has not taken action and sent any warnings about icing.
They are also furious with the dissenters for going on their own tour, spreading conspiracy theories and convincing the opposition party (which was the Liberal Party) to call for a public inquiry.
The dissenters are furious that their calls for a public inquiry has not been successful, as the Transport Minister had backed the report.
The investigators themselves are furious that their own integrity has been questioned and compromised by unknowing journalists and dissenting Board Members that have verbally abused them to the point where morale has cratered.
On March 9th, 1989, it probably felt like the investigators just wanted to be out of the spotlight, and hope that nothing serious happens until a new board is created, where they would be protected from Board Members by law. If they were thinking that, then they were in for a rude awakening.
Air Ontario Flight 1363
March 10th, 1989 was the Friday before March Break for Ontario primary and secondary school students. Many families in the city of Thunder Bay, Ontario, on the northern shores of Lake Superior, were wanting to board flights to get to their vacation spots, some via Winnipeg’s International Airport. Air Ontario Flight 1363 was one such flight connecting Thunder Bay to Winnipeg, via a stopover in Dryden, Ontario, being flown with a Fokker F28, a short-range jet liner, registered C-FONF.
Air Ontario Inc. was a regional air carrier that was a result of a “functional merger” between Austin Airways Ltd. and Air Ontario Ltd., which used to be called Great Lake Airlines (this was not actually a merger per say, but Austin Airways bought all of the assets from Air Ontario Ltd., then renamed themselves Air Ontario Inc., while the asset-less Air Ontario Ltd. was no longer a company). The airline was 75% owned by Air Canada, while 25% was owned by the former owners of Austin Airways, the Deluce family.
Since it was mostly owned by Air Canada, passengers could book their entire itinerary through Air Canada, even if they were taking an Air Ontario flight, like how it works for regional carriers in the US and Canada today. Many passengers on Air Ontario 1363 were doing just this, planning to take connecting flights from Winnipeg. In total, there were 66 passengers that were on the Thunder Bay to Dryden leg and, after eight passengers deplaned and seven passengers boarded the plane, 65 passengers would be on the Dryden to Winnipeg leg.
When the flight arrived at Dryden, it was already about an hour late due to delays from the incoming leg and problems in Thunder Bay. Usually, the plane would not need to be refuelled in Dryden, but the anticipated holiday rush meant that Air Ontario planned for this flight to carry less fuel from Thunder Bay, and forced a refuelling in Dryden. This refuelling was made even more risky with the fact that C-FONF did not have an operable APU for the past few days, and Dryden had no ground-start equipment. If the pilots shut down both engines in Dryden, that would have grounded the plane until Air Ontario sent ground-start equipment from Winnipeg: a costly endeavour.
This meant that in Dryden, the pilots had to keep one engine on at all times, including during refuelling. Refuelling with an engine running is called “hot refuelling”, and it is dangerous, so much so that fire trucks are required to be nearby during the refuelling. Despite the dangers, hot refuelling was still allowed with passengers on board at the time.
The plane was refuelled successfully as the weather changed throughout the stopover. What was light snowflakes that melted on contact with the ground became heavy snowfall, enough for a Cessna to return in a state of “urgency”, as the pilot was not instrument-rated, and the conditions fell below VFR limits. This Cessna landing delayed the flight even more, as they were prepared to go onto the runway to take-off. All throughout its time in Dryden, snow accumulated on the wings, but the crew did not de-ice.
Finally, at 12:09:40pm local time (CST), Air Ontario 1363 commenced its take-off roll, about 70 minutes behind schedule. After initial rotation at the 3500 foot mark, the plane settled back on the runway until another rotation and lift-off from the 5700 foot mark (out of the 6000 foot runway). At the end of the runway, it was only 15 feet above the ground, and never really gained altitude. It was subject to the ground effect, before striking trees. Fire broke out on the left side before it crashed onto that left side, which is reflected in the fatality count based on the seat map. A fire developed, and the crash resulted in 24 fatalities, 2 of which happened in hospital, and 45 survivors, 37 of which were injured, 18 of which required hospitalization. Of the 4 crew members on board, only flight attendant Sonia Hartwick survived. The other flight attendant, Katherine Say, and the two pilots were among the 24 fatalities.
Even though the plane crashed around 12:10pm, and fire-fighters were on scene within 10 minutes, they did not actually start fighting the fire until 2pm, becoming more focused on the survivors than their jobs as fire-fighters. As a result, the fire burned for a lot longer than it should have, and as a result, the CVR and FDR were so damaged by the heat that they were unrecoverable. The flight path of the plane had to be reconstructed based on eyewitness testimony from inside and outside the plane. Like in the case of Arrow Air Flight 1285, we have no idea what happened in the cockpit.
Initial Investigation
Despite the surrounding controversies, the CASB started their investigation into the accident, and were all in Dryden by the next day. After the shitshow that was Arrow Air, they left nothing to chance. Nothing from the accident scene was moved. Not even the bodies of the people that died on the plane.
They took photos of everything, and filmed everything. A search and rescue team searched for anything between the end of the runway and the crash site, with a width of 100 metres. Every single piece of wreckage was marked on a map with its location and photographed before being removed. Heights of the spots where the plane hit the trees were determined with “vertical colour and infrared photography and subsequent evaluation using photogrammetric techniques”. Only after they documented and examined every single piece of wreckage did they ship it to the CASB engineering lab in Ottawa. After the snow melted, they did the same thing: find wreckage, photograph and film it, mark it on a map, then send it to Ottawa. They did not fuck around. By March 29th, 1989, they completed their “field phase”, which included about 100 interviews being conducted.
On March 29th, however, the CASB had to suspend their investigation. Benoît Bouchard, transport minister at the time, saw the writing on the wall. The CASB’s integrity was destroyed and their investigation into this crash was probably not going to be trusted. In addition, the TSB was going to exist exactly one year from that date (legislation hadn’t yet been reintroduced to bring in their existence since the reelection of the Progressive Conservatives, but was going to be by April 7th), making the CASB a lame duck organization. In addition to announcing a judicial review of the Arrow Air investigation, he would announce a judicial inquiry into the Air Ontario crash. According to Paul Koring of The Globe and Mail, Bouchard said that ““the actions I have taken will assist in restoring the credibility” of accident investigation”. Bouchard even said that if any other major crashes happened before the TSB was established, they would get judicial inquiries too.
The judge Bouchard chose for this daunting task had to be a senior trial judge with an aviation background. In the Court of Queen’s Bench of Alberta (Alberta’s superior trial court), there was the perfect man for the job: Justice Virgil Peter Moshansky.
Moshansky Steps In
Monshansky was the literal perfect man for the job. He was a pilot that had over 2000 hours of experience, and owned a Piper Arrow that he flew all the time, including flying all over Alberta to hear cases. Not only was he a pilot and a member of various pilot clubs, but he was very interested in plane crashes and air safety. According to an article by Michael Tenszen of the Toronto Star, his favourite reading was flying magazines and official accident reports. He loved flying so much that he was even thinking of making the long journey from Alberta to the Dryden inquiry on his Piper Arrow, before deciding to just fly on a commercial flight.
I’m sure when the producers of Mayday called him to ask for an interview about the Dryden crash, he was probably ecstatic to be on his favourite television program*.
*I’m making this point up, but I wouldn’t be surprised if it was actually true.
So when Prime Minister Brian Mulroney’s principal secretary called him to ask if he could take up the job, he did not hesitate.
Throughout most of the inquiry, he did it with a heavy heart, as his brother, Greg Moshansky, died in the crash of a DHC-2 Beaver, registered
C-GUJY, in Great Slave Lake in the Northwest Territories on August 21st, 1989. This may have made him more relatable to the survivors and the families of the victims, as he was going through similar feelings. After the Commission, they had nothing but praise for him.
Reaction
When Bouchard made the announcement of the inquiry and review, there were mixed reviews, but everyone understood why it was happening.
The Chairman of the CASB Ken Thorneycroft even remarked that ““if you had to report to the current board, you probably wouldn’t be too upset either” at the turn events have taken”, according to an article by Paul Koring for The Globe and Mail, possibly referring to the relief that investigators may have had when they realized that the Gang of Four were not going to hound them with ridiculous requests.
Speaking of the Gang of Four, Ross Stevenson and Les Filotas thought that it was a positive, as “they believe[d that] the board investigators will follow directives from the judge, resulting in a more complete investigation,” according to an article by Patrick Doyle for the Toronto Star, not realizing that Moshansky would have much more reasonable directives. An unintended side effect is that, with the Dryden crash out of their hands, the Gang of Four would have more time to write emotionally manipulative letters to the victims’ families of Arrow Air.
According to the Canadian Press, this investigation was “expected to set a precedent in the way Canada responds to air disasters” and “expected to become a model for other air accident investigations”.
Setting up the Commission
Moshansky made sure to get everything set up so that he could reopen the investigation as quickly as possible. He had the inquiry placed under the supervision of the Privy Council (a body of the Canadian government that is purely there to celebrate special occasions in the monarchy consisting of past and current prominent politicians) and funded directly from the Treasury Board, considering the fact that Transport Canada would be scrutinized throughout the inquiry.
Some other things he did was set up the Commission offices in the Atrium Building on Bay and Dundas in Toronto, hired Frederick von Veh as Commission counsel and Gregory L. Wells as associate Commission counsel, and decided to hire a few independent advisors: Charles Miller (of DC-10 cargo door investigation fame) and Gerard Bruggink, both of whom were formerly of the NTSB, as special advisors, and Canadian aviation experts Frank Black (interviewed on Mayday) and Robert MacWilliam as technical advisors. He also hired Gordon Haugh as a communication advisor, basically the spokesman of the Commission.
Moshansky had two meetings with the CASB members on April 11th and 13th, to basically give control of the investigators who were investigating the Air Ontario crash and all documents pertaining to it to the Commission, which they agreed to. They also allowed the Commission to use the CASB facilities and resources in Hull. After the second meeting, Moshansky gave the go-ahead to the investigators that they could resume their work. Some of the people seconded from the CASB to the Commission were the investigator-in-charge Joe Jackson, and three aviation technical experts: David Rohrer (interviewed on Mayday), Reg Lanthier, and David Adams, who was actually already seconded to the CASB from Australia’s Bureau of Air Safety Investigation (which was later merged into the ATSB).
Goals
It is worth noting that this Commission is different from a regular accident investigation. Though the primary area of concern is “determining the contributing factors and causes of the crash”, it was also there for “the need to re-establish the confidence of all Canadians in the aviation accident investigation process” and that if “fundamental flaws are found in this process, then appropriate recommendations will be made”. The Commission was casting a much wider scope than just this accident.
David Adams was interviewed by the National Library of Australia in 2004 about his life in aviation, and mentions this Commission. He claims that this Commission used a blueprint from the Royal Commissions done by New South Wales. He also tells of an embarrassing incident two months in, where he and von Veh had a brief confrontation where Adams smugly said something about the Commission having all of these lawyers and police officers and yet being nowhere closer to figuring out the cause of the accident. Von Veh then put him in his place by saying:
“This Commission isn’t about determining what caused this accident. This Commission is about assuring the Canadian public that they can have faith in their transport systems.”
After which, Adams just shut his mouth and went to his office. This line is the real insight into this inquiry. The Air Ontario crash may have been the centrepiece, but it was really about accessing aviation safety in Canada, similar to the Dubin report. It is just that this is from the view of what allowed this accident to happen, and any other unsafe practices that could be found in the meantime to be rectified.
Moshansky also decided to experiment with this Commission. The CASB was pretty much dead, and the TSB was on the way, so ideas that may not have been possible under the laws that governed the CASB were possible in this Commission. With that, they invited a number of individuals from the “interested parties” to become full participating members of the investigation, never before done in Canada, but seemingly similar to the “party system” used by the NTSB.
Initial Findings
This series is about the history of Canadian aviation investigations, so I wouldn’t want to cover this accident investigation in full. However, as it seems like the Admiral is not going to revisit this accident for quite a while, I will go into this investigation before connecting this back to the ways this changed accident investigation in Canada.
One of the first things that was noted from this investigation was the hot refuelling, specifically with passengers on board. The Commission found this practice filled with so many unnecessary risks that, just four months after the crash, they recommended to the Department of Transport that hot refuelling should be banned in situations where passengers on board, passengers are boarding, or when passengers are deplaning. The recommendation was actually put into practice by October 1989, before the first interim report was even released.
The real elephant in the room is wing contamination. Everyone would be screaming at the crew: “Why didn’t you de-ice when there was snow on the wings?” They can’t answer, they’re dead. Also, they can’t directly answer via the CVR because that was unrecoverable. However, the investigation tried to answer this question for them to the best of their abilities.
The Crew
The cockpit crew consisted of a captain and first officer. The captain for this flight was George Morwood, who had 24,100 flight hours. He was with Great Lakes Airlines since 1973, and joined Air Ontario Inc. in the merger. Even with all of that experience, he only started flying the F28 since January 1989, and had only 81 hours on type. Prior to this, his only jet experience was 591 hours on the Grumman Gulfstream II, which was between 1970 and 1973. He was considered a “by-the-book” captain, and always had the passengers in mind, both for their safety and their experience, making sure they were on schedule. He could get under the nerves of some pilots with his attitude of how things should be, but people thought he was a good captain.
The first officer was Keith Mills, who had over 10,000 hours of experience, including about 3500 hours of the jet-powered Cessna Citation, and just 66 hours on the F28, only starting to fly the type a month prior. He was with Austin Airways since 1979, and joined Air Ontario in the merger. He had trouble during his training on other aircraft types, and had to do his F28 training on the plane itself whenever the plane was available from Air Ontario, which would have been at night, and not in a simulator, as simulator time was hard to get. Nevertheless, he was qualified to fly the plane.
Morwood was known for being overly cautious about his passengers. In fact, a bit of that delay from the incoming leg involved him de-icing the plane in Winnipeg. So why did he not do that in Dryden? Some of that answer was already talked about: the one running engine. Air Ontario had a policy of prohibiting de-icing with at least one engine running. To him, it seemed like a rule that could not be broken. There is one case of Morwood being extremely worried about the engines intaking de-icing fluid on February 26th, 1989.
At the same time, Morwood inquired about de-icing at Dryden before his ill-fated take-off, showing that he did care about it. Still, it does not answer why he even took off at all. Part of that is the circumstances. It was a Friday before March Break; passengers are trying to get to their connecting flights in Winnipeg; Dryden is a small city in the middle of nowhere. If he stopped his engine to de-ice, Air Ontario would have had to fly in ground-start equipment, which would have taken hours and cost them greatly. Worst case, it would have forced the passengers to stay in Dryden for the night, which would have been undesirable for trying to find rooms there for 64 people (one passenger would have had a special room in jail; he was being escorted to Alberta by two police officers to face a few criminal charges and was in handcuffs when the plane crashed).
The other part of the answer as to why Morwood even tried to take-off is his background: most of his experience was not on jets. He had experience de-icing on his previous types even though some people, including people from Transport Canada, thought it was unnecessary and told him that “the snow would just blow off at take-off”. It would be so easy for those words to infect his mind and make him think “people said that in prop planes. This jet could easily blow off all of the snow.” This is despite F28 training that specifically warned him not to take off with any wing contamination, because there were two previous accidents involving this type of plane and icing conditions. It didn’t help that Morwood was in a similar position as his passengers, and had a vacation coming up the next day.
There is yet another reason why Morwood elected to take off: lack of knowledge. Specifically, about “cold soaking”, where cold fuel causes the parts of the wing in contact with the fuel to be cold enough for ice to develop. While there is evidence that Morwood and Mills knew about this phenomenon to some extent, it was never brought up in training. Most pilots in Air Ontario knew about it, but some did not, and those who did know only learned about it through personal experience and probably did not realize its full potential, like Morwood. If the effects were properly taught in training, no one would even dare try to do what Morwood tried, including Morwood himself.
To truly show that cold soaking is the reason why Air Ontario 1363 crash, we go to the survivors. There were pilots on board that saw the wing, and thought that the plane wouldn’t fly before take-off even started. Even Sonia Hartwick, the lone surviving crew member, saw something very troubling. When the take-off got started, she was staring at the wing. At a certain point, snow did blow off. However, what lay underneath was a sheen of clear ice covering the wing. Unlike in Arrow Air, people saw ice on the wings and lived to tell it.
De-Icing
So it seems like we have built up a probable cause for the accident. Case closed, right? No.
Remember what Adams said about what von Veh told him:
“This Commission isn’t about determining what caused this accident. This Commission is about assuring the Canadian public that they can have faith in their transport systems.”
Morwood was clearly affected by a cultural attitude that snow will blow off, and that you don’t need to de-ice even if there is some contaminants are on the wing. In fact, that is even implied in Canadian standards. In those standards, it states:
“No person shall commence a flight when the amount of frost, snow, or ice adhering to the wings, control surfaces or propeller of the aeroplane may adversely affect the safety of the flight.”
That implies that there are situations where frost, snow, or ice adhering to the wings may not adversely affect the safety of the flight, which is clearly not true, and even if it was, how could a pilot know when those situations are possible? The Commission saw this and, along with the statements made by Hartwick and the pilots on board that will be discussed later, made three more recommendations in the first interim report that said to:
- change that standard to basically prohibit flight with frost, snow, or ice on the plane;
- implement a program involving all crew members (cockpit, cabin and ground) about the dangers of wing contamination; and
- to make sure that the crew checks the wings to make sure they are clean before take off, and that any cabin crew can report an unclean wing to the pilot-in-command.
This interim report was released on December 8th, 1989, and according to Don Dutton of the Toronto Star, Bouchard announced that all Canadian airlines must de-ice their wings if there is frost, ice, or snow adhering to the wings, no exceptions. He also accepted the recommendation that called for a “safety awareness program” for all flight and ground crews on the dangers of wing contamination, and that if cabin crew or ground staff call the captain to check the wings, the captain must check it for themselves.
Even when the recommendations about having a “clean wing” are seemingly being put in place, Moshansky and his team were still finding issues with the fluid that supposedly de-ices the wings at all.
The Second Interim Report
On December 11th, 1990, a year after the interim report was published, Moshansky did something unusual. With the Commission still deep within their investigation, he published a second interim report. In most investigations and most inquiries, they would publish one interim report and final report. However, the Commission’s investigation found so many serious flaws in Canada’s air safety measures that they felt compelled to submit this report with many recommendations to improve safety for the upcoming winter season. They found more problems with de-icing.
The report consists of three main parts: Toronto Pearson airport, de-icing fluids, and runway-end de-icing pads.
Toronto Pearson
When the Commission investigated de-icing practices at Toronto Pearson, they were shocked that there had not been a crash at that airport related to icing. At the time in Toronto, a plane could get de-iced at the gate or at a certain ramp area on the apron. However, the taxi distance between a de-icing and the end of a runway would be 2–3 miles, depending on the departing runway being used. Also, the amount of taxiways at Toronto Pearson was woefully inadequate for the busiest airport in Canada, causing loads of congestion. To add insult to injury, this was during the construction of Terminal 3, so the problems of congestion was going to get worse by the next year. These factors caused delays from 25 minutes to over an hour between de-icing and take-off. Coupled with the holdover time of the type of de-icing fluid used, planes in Toronto were certainly taking off with wing contaminants despite the change in standards brought in from the first interim report.
These problems really showed themselves during a winter storm in Toronto on February 15th, 1990. Air Canada co-ordinators instructed the de-icing crew to de-ice the planes with hot water, then immediately apply the Air Canada type II anti-icing fluid that was recently introduced. If you noticed, hot water can freeze quickly in a winter storm. So, the wings were freezing before the type II fluid could be applied. The true horror was shown when a de-icing checker, when prompted, put his hand underneath the type II fluid, and felt ice. He was rightly pissed. He had no training on this new type of de-icing fluid, and that this procedure was causing ice to form on the wings.
Air Canada co-ordinators gave these instructions at the start of the day at 5am, and when the crew advised at 10:30am them that the wings were freezing and asked to use a 30% glycol/70% water solution to de-ice instead of just hot water, the co-ordinators refused, and insisted that the hot water be used. These planes continued to be improperly de-iced until 7pm, where Air Canada finally decided to stop operations.
Types of De-Icing Fluid
Before this report, in Canada, except for the brief time where Air Canada had its own type II fluid that was horrifically misused in the aforementioned snowstorm, the only de-icing fluid used was type I, heated to 180ºF (or 82ºC). This is a glycol-water mixture that removes surface contamination. Unfortunately, the holdover times (which is the time it takes from application to the point where ice can form on the surface again) is not long. In non-freezing precipitation, it has limited anti-icing properties, and can have a holdover time of a maximum of 15 minutes. In freezing precipitation, it’s even worse, having a holdover time of as low as one minute. On a large plane like the Boeing 767, de-icing could take 5 to 10 minutes, which would mean under certain weather conditions, it would be useless before the work was even done!
This information was actually shocking for many pilots. They were given documentation that this de-icing fluid could last 15 minutes in freezing precipitation, which itself was an improvement over previous documentation that claimed a half an hour holdover time for the same conditions. Some did not even know the difference between type I and type II fluids, which I will talk about soon.
The Commission compares these paltry Canadian actions on de-icing to the actions taken in Europe. At the time, the major airlines of 21 European countries were in the Association of European Airlines, or AEA. For 20 years, they were using a standardized de-icing and type II anti-icing fluid. The AEA type II fluid is a glycol based anti-icing fluid with corrosion inhibitors, wetting agents, and polymeric thickeners. According to Frank Black on Mayday, it was a mucus-like substance. Unlike type I, it is applied at ambient temperatures, and provides a holdover time of about 45 minutes in freezing precipitation. By 1990, the AEA was on its third generation of type II fluid, which had shearing properties of type I. This allows the fluid to “blow off” on take off, at around 100 knots, unlike previous generations that would have resistance in shearing off at take off speeds.
This was not a secret fluid. Every plane that entered an AEA country had to use this fluid in adverse conditions, including Canadian planes. The Commission found that in the past 20 years where type II was used, there was not one crash related to ground icing (this statistic would change with SAS 751 [linked is Admiral Cloudberg’s article] on December 21st, 1991, where the MD-81 crashed shortly after take-off, partly due to the engine’s ingestion of broken-off ice from the improperly de-iced wings. Judging by that investigation, the lack of a crash in that 20 year span was just pure luck that an SAS plane didn’t crash).
The differences between Europe and Canada was quite contrasting. Even Air Canada’s briefly used type II fluid had half the holdover time that AEA’s had. The priorities of de-icing were so low that even with their own type II fluid, a bulletin issued by Air Canada mixed up the damn colours of the different types of de-icing fluid! Moshansky himself wondered, “why not just use the AEA type II fluid itself instead of trying to reinvent that fluid?”
Runway-End De-Icing Pads
With all of these holdover times being a problem with congestion, there is a simple solution: just de-ice as late as possible before take-off. This is done by have de-icing pads next to the runways, allowing for a quick take-off after a de-icing. In a cold country like Canada, these should be everywhere, right?
At the time of the second interim report, there was only one airport in the whole country that had this: Dorval Airport (now called Montreal-Trudeau Airport). Toronto, Edmonton, Calgary, Winnipeg, none of those airports had runway-end de-icing pads despite the obvious snowy conditions these places encounter, not to mention the other small airports in the more northern areas.
The collective of these factors compelled the Commission to release their second interim report, highlighting these three topics. In it, it provides 13 recommendations, including the need for runway-end de-icing facilities and to have interim ones until a more permanent one could be built at Toronto Pearson, expanding the amount of ramp space at Toronto Pearson, and to use AEA type II anti-icing fluids.
This report was given to the Prime Minister’s Office, and should have been to ICAO, where it would have been available to anyone in the aviation sector, from airlines to investigative agencies to regulators.
USAir Flight 405
I know this series is about Canadian aviation investigations, but anyone who’s covered Air Ontario Flight 1363 must also touch on USAir Flight 405. On March 22nd, 1992, just days before the Commission’s final report was to be published, USAir Flight 405, a Fokker F28, attempts to take-off from LaGuardia Airport in New York City. It did not stay in the air for long, and ends up crashing in Flushing Bay just beyond the end of the runway. 27 of the 51 people on board died, including the captain. When Moshansky heard about the crash, he exclaimed “My God, it’s Dryden all over again!”
Many problems were exposed by the NTSB. LaGuardia only used type I fluid. They only de-iced at the gate and had no runway-end de-icing pads. There was a lot of congestion at the airport that delayed take-off and ran out the clock on the usefulness on the de-icing fluid in the bad weather. Sounds familiar? The Commission thought so too. Their second interim report aimed to stop this, and was released on December 11th, 1990. So why didn’t the FAA read this report and apply it to the many airports in the US that had this problem?
This is where I have to step in. In the episode of Mayday, the narrative implies that the FAA had the report but just never read it, and that the FAA denied ever receiving the report just to save face. However, articles from March 31st, 1992 indicate that Gordon Haugh, the spokesman for the Commission, admitted that no one from the Commission ever sent that report to the FAA. When they sent it to the Prime Minister’s office, the Canadian government somehow forgot to send the report to ICAO. Therefore, the only entities that had a copy of the report were the Canadian government, and a few key people, Chuck Miller, Richard Adams (formerly of the FAA), and Eugene Hill (of Boeing). Adams and Hill were key witnesses in the inquiry.
Since the government never forwarded a copy to ICAO, neither the FAA nor USAir could ever know that it was available. While there is the issue that the FAA never asked for it (as the publication of any aviation report being reported on in the media must get at least some American aviation eyes, even if it’s reported in Canadian media), the fact is, no one gave them this report. When Moshansky says in Mayday that his report “was probably sitting on someone’s desk”, I do not think he is referring to the FAA despite the implication created by the episode. I think he was referring to the Canadian government.
There is a possible, hidden reason why the government may not have sent this second interim report to ICAO. It was a Commission of Inquiry, not a normal accident report. The entire reason why the Commission existed was because the investigative agency lost legitimacy, but it could be thought that if an investigative agency actually made the report (whether it was the CASB or a TSB that came into existence in 1988/89 had Bill C-142 been passed before the election), the government would see “CASB/TSB interim report”, and immediately forward that to ICAO. However, a report from a Commission of Inquiry may not have that immediate reaction. A person looking at the table of contents would see “Winter Operations at Pearson International Airport” and think that this was meant to be for Canadian uses only. It was also only vaguely related to the Air Ontario crash, so they probably thought that it didn’t count as a report on it in ICAO eyes. This is just speculation on my part and could be completely wrong, but this is my best guess on why ICAO never got this report.
Final Report
On March 26th, 1992, just shy of three years since the Commission was created (and just shy of two years after the TSB was established and the final report’s intended release date), Moshansky published the Commission’s final report. It was in three volumes, plus a fourth volume full of appendices, and well over 1000 pages. Including the recommendations made in the two interim reports, there were 191 recommendations made throughout the entire Commission. The report consists of nine parts:
In Volume I:
- Part 1: Introduction
- Part 2: Facts Surrounding the Crash of Flight 1363
- Part 3: Crash, Fire-Fighting, and Rescue Services
- Part 4: Aircraft Investigation Process and Analysis
In Volume II:
- Part 5: The Air Carrier —Air Ontario Inc.
Volume II is Part 5. The Commission found so many things wrong with the airline that well over 450 pages was dedicated to the time spent analyzing them.
In Volume III:
- Part 6: Transport Canada
- Part 7: Human Factors
- Part 8: Legal and Other Issues Before the Commission
- Part 9: Consolidated Recommendations (all of the recommendations listed throughout the reports are grouped together here).
Also, General Appendices.
The Final Report is quite hefty, and to cover it all would break my mind. I will definitely not go into as much detail as I did with the second interim report, but to greatly summarize:
Air Ontario was expanding rapidly with its acquisition of Fokker F28s, even though most of their pilots had little experience with jets. No one experienced with them was hired for a long enough time to make the transition easier. The jets themselves were not in great shape either, and they were deferring maintenance, taking advantage of an unapproved MEL, especially with the APU. When Morwood got the plane on March 10th, he was probably not happy about the inoperative APU. Since it was a Friday before March Break, passenger load factors were expected to be high, forcing a refuelling in Dryden, even though Dryden had no ground-start equipment.
The plane gets further delayed in Thunder Bay when Air Ontario unexpectedly puts ten more passengers on board than expected, as a flight from Canadian Partner got cancelled and some passengers got moved to this flight. Since Morwood planned his fuel load to be as high as possible to comply with a further away diversion airport, the full plane meant that the fuel load made them overloaded in terms of maximum take-off weight. Despite Morwood’s objections to the extra passengers, the dispatcher forces him to offload fuel, delaying his flight even more than it already was. This extra delay adds in the snowy weather element in Dryden that was not expected had they been on schedule, and neither Morwood nor Mills saw this weather change in a weather report.
At Dryden, Morwood goes to the Air Ontario desk in the airport terminal to make a phone call to dispatch. Meanwhile, the flight makes the risky manoeuvre of hot refuelling with a full passenger load, which ended up being banned before the first interim report was even released. The one running engine also makes de-icing the plane “off the table” given Air Ontario policies. Morwood gets into a heated conversation with the dispatcher, to the point where he ends the call by slamming the phone. Despite the people on the other side of the phone call saying that nothing serious was talked about, some in the Commission believe that the heated conversation was about the possibility of cancelling the flight and the headache that would cause.
When Morwood returns to the plane, he is not happy. However, he also notices the snowy weather, and so asks the refuelling agent if there is de-icing at Dryden. The agent points at the de-icing vehicle. At this point, the timeline could diverge with our timeline, where Morwood decides not to de-ice, and an alternate timeline, where Morwood decides to go against Air Ontario policy and de-ices with an engine running.
In the alternate timeline, the Dryden crew de-ices the plane with the only fluid available…type I de-icing fluid, and gives the passengers a nauseous odour through the engines. Now remember, in freezing precipitation, this fluid can have a holdover time of as short as one minute, so with this de-icing, they have to take off quickly to avoid accumulating lots of wing contamination. But, they probably don’t know the extreme time pressure they are under due to faulty knowledge, and by the time the de-icing is finished, they go to taxi onto the runway, but remember? A Cessna calls in to keep the runway clear, because that pilot got caught in IFR conditions without IFR training. The Cessna lands safely, but by that time, the de-icing fluid is already useless. Snow is falling onto the cold soaked wing, and freezing ice onto it. By the time they backtaxi the runway and take off, they might as well be in our own timeline.
Essentially, the only safe solution was to incur the cost of housing 64 passengers in the smallest city in the middle of nowhere Ontario plus the cost of flying ground-start equipment. Many rescheduled flights, plus a personal delay of a vacation for Morwood. In the culture Air Ontario had, that was impossible to choose.
Instead, Morwood and Mills are infected with the mantra “the snow would just blow off the wings, and it’ll be fine”. They did not take into account cold soaking, which would have guaranteed ice formation on the wing even though the temperature was only hovering around freezing. They also don’t get warnings from the cabin crew, where there were passenger concerns about the wet snow on the wing. There were four people in particular that were worried: Dennis Swift, Captain Berezuk, Captain Haines, and Sonia Hartwick herself.
The two pilots, Berezuk and Haines, believed that they were going to be de-iced, and when the take-off roll started, they thought it wasn’t going to fly. They did not say anything because of reasons ranging from the thought that the F28 had its own built-in de-icing system to take care of the wings, to a simple “pilot professional courtesy”, which basically precludes an off-duty pilot to bring to attention a safety concern to the on-duty crew. After all, captain knows best.
How deep does this “professional courtesy” go? Investigator David Adams had quite the anecdote to tell. After he had participated in the CASB investigation at the crash site in Dryden, he was on an Air Canada Boeing 727 in Thunder Bay, waiting to depart to Toronto, when he noticed a half an inch of wet snow on the wing. Even though he is a knowledgable investigator and just participated in an investigation of a crash that was suspected to have been caused by snow and ice on the wings, he was hesitant to tell the crew of his observation. Even when he brought it to the attention of a flight attendant, he merely requested the flight attendant to ask when the captain would be de-icing. Luckily, the flight attendant complied with the request, and only about 90 seconds after did the captain announced to the cabin that the flight would be delayed while de-icing took place. That’s how deep it goes.
Dennis Swift, one of the RCMP officers escorting Gary Jackson to Alberta to face charges, was the only person that actually asked Katherine Say, the lead flight attendant, directly about what the pilots were going to do about the wings. According to Sonia Hartwick, the sole surviving crew member, Swift asked Say when the pilots will de-ice. Say said something about the in-built de-icers. When Swift pointed out that these only de-ice the leading edge and not the entire wing, Say just shrugged and looked at Hartwick. Eventually, Swift resigned himself to the same old saying: captain knows best. Say never told the cockpit about the worried passenger.
However, Sonia Hartwick was nervous. She had the feeling that the cockpit crew did not accept the cabin crew as a part of the crew, based on previous experience. So, she didn’t speak up either as, while not necessarily this cockpit crew, some cockpit crews validated this feeling of not taking her concerns into account. To be fair, other crews actually listened to her concerns. Nevertheless, this extreme variation in crew culture is a failure by Air Ontario in terms of CRM training, where the C stands for Crew.
When Swift did not continue to press Say, Hartwick was very uncomfortable. She thought about Arrow Air 1285, not knowing that there was supposed to be a bulletin sent by Transport Canada about the dangers of not de-icing to Air Ontario because of Arrow Air, but somehow only arrived five days later. I couldn’t imagine the horror when the wings went from snowy to icy in front of her eyes during the take-off roll. According to an article in the Toronto Star when the final report was released, she still felt “personally responsible” for the deaths.
With all of that, in the state of mind the cockpit crew was in, they attempt to take off. The take off fails, and they crash, killing themselves and 22 other people. Fire-fighters were on the scene within ten minutes, but they are so distracted with helping the survivors that they neglect to start fighting the fire for almost 2 hours, by which point the recorders become unusable.
The Commission also found that Transport Canada was not taking into account air safety during their deregulation phase of the 80s, to sum up a sizeable part greatly. They also did not adequately regulate Air Ontario’s F28 operations, especially the unapproved MEL.
The Commission’s statements on the investigative process itself is the most interesting, at least in the context of this series, because it had a lot of suggestions to improve the TSB’s way of investigating and, in fact, changed ICAO’s Annex 13.
The Investigative Process
When Air Ontario Flight 1363 crashed, the CASB initially started their investigation. Its integrity was in tatters over the Arrow Air investigation, and the TSB was already known to be on the way. On March 29th, 1990, exactly one year after the Commission was created, the CASB ceased to exist and the TSB became a thing. This provided a unique lens into how the TSB’s investigative process could be improved from the observation of the CASB’s last ever major investigation, and could also comment on the recent TSB legislation.
One notable thing about the Commission’s investigation is that it took a huge deep dive into the effects of the management of Air Ontario had on the crash. Like I said, the entire second volume was dedicated to Air Ontario, and they saw that if Air Ontario’s management was more committed to safety, the crash would never had happened. It was probably the first major investigation to ever take into account air carrier management in a huge, substantive way.
Recommendations #175 and 176 basically say that the TSB should expand their human factors investigation to include a comprehensive section on the effect of the air carrier management, to encourage examination of management failures when coming up with the causes into the accident, and to have the TSB basically convince ICAO to amend their documents to include such a thing. By 1994, the eighth edition of ICAO’s Annex 13 included in their template of a final report 1.17. 1.17 is in the “1. Factual Information” section, and it has the label “Organizational and management information”, which essentially covers this point.
Now, for the observation of the investigators themselves. While Moshansky probably thought that these investigators were good for the most part, particularly being impressed with Joe Jackson, David Rohrer, and David Adams, he found a lot of issues that he felt needed correcting, from training to the TSB act in general.
Firstly, there’s the issue of the fact that according to the law, only the TSB investigators could fully participate in the investigation. The best interested parties could get to be involved was “observer-invitee”, which is limited by definition, and was excluded from examining CVR recordings, ATC recordings, and witness statements. The only observers allowed to participate in that area were ones designated by the Minister of Transport. The Commission saw great results from allowing representatives from interested parties to be full participants in the investigation. The Commission recommended that the law be amended to allow for representatives from interested parties to be a part of the investigation. Despite this, it has not changed to fully reflect this recommendation, and in fact, currently no observers are allowed to examine CVR recordings nor witness statements at all! However, ATC recordings no longer have the same protections, as anyone could listen to the radio frequency and make their own recording.
Moshansky also hired independent experts to help out in the investigation. The law actually allows for the TSB to hire, on a temporary basis, independent experts with technical or specialized knowledge, provided there is no conflict of interest, and Moshansky wants the TSB to use that to its fullest advantage. He points that even the best investigators, even when gaining investigative skills, can lose touch to newer technologies, and also not be expected to be knowledgable in everything. An interesting recommendation, #183, suggested that the TSB have a roster of “highly qualified Canadian and international professional experts”, which has their names and phone numbers, while #184 suggested that the TSB have a closer relationship with the National Aeronautical Research Establishment and the National Research Council Canada.
On the investigators themselves, Moshansky saw troubling signs of a lack of training in certain areas. For example, numerous interviews done by the CASB before the Commission took over did so little to advance the investigative process that those witnesses had to be reinterviewed by the Commission. Human factors, though investigated with its own unit, were not yet “fully perceived human factors as a legitimate pursuit.” He also found the lack of forensic training for TSB scientists, where forensic means “of or in relation to courts of law”. These scientists were not comfortable nor knowledgable in presenting their evidence in the witness box, and did not realize the importance of things that would make their evidence lacklustre in the context of a court of law.
In my opinion, this probably led to the distrust of investigators by the Gang of Five/Four which destroyed the CASB. The scientists that worked on the Arrow Air investigation probably could not properly present their argument to a suspicious group of disgruntled board members.
In terms of fixing these problems, the TSB, by 1991, were already at work training their investigators in witness interviewing, and such training was made mandatory. As for forensic training, some note that there is a specific section in the law that states that an investigator should not be a witness in a court of law unless in special circumstances or if they are called to a coroner’s proceedings. The field of human factors would only continue to improve over the years, with the TSB providing training to field investigators and head office safety analysts.
Overall, having an investigation under a judge who is very interested in aviation investigations gave the Canadian investigators an outsider view of their practices, and, while not implementing all of his recommendations, implemented changes that would improve further investigations. They did not change their rules about not having representatives of interested parties full participant status, but they probably allow more input from those observers. There may not be forensic training, but scientists are probably more aware of how to strongly defend their findings. Seeing how the TSB was fully committed to take the suggestion of implementing mandatory witness interviewing training, I’m sure that in whole, the TSB made the appropriate changes that would fit in their style of investigating that followed the spirit of those recommendations.
Conclusion
In July 1991, the government created the Dryden Commission Implementation Project (DCIP), which was responsible for managing the implementation of their recommendations. They released a report called “Final Response” in July 1995, and it lists everything that has been done for the 191 recommendations up to that point. When the Commission’s final report was released in March 1992, 35 were already implemented. A further seven were implemented by September 1992. By the final response, 130 recommendations in total were implemented, and most of the rest would be implemented when legislation allowed for the changes.
The Dryden Commission was impactful in that it was a trustworthy investigation after the debacle that was Arrow Air 1285. However, it may have inadvertently made any Canadian investigation less credible unless it was under an inquiry. The release of Filotas’s book in 1991 didn’t help matters either, and so, after the release of the Commission’s final report, the TSB was in an era unknown to them: still eyed with suspicion, and now without the backing of a judge. Over the next few years, the TSB would have to work to regain trust. A review of the TSB would start in 1993, and when the review was completed by next year, the review team still found flaws within the Board, which I will talk about next time.
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If you’ve gotten this far, thank you for reading! This article was hard to write. I knew going in that the Moshansky report would be a nightmare to read through, but it was important for me to at least try to do the crash proper while leaving enough room for Admiral Cloudberg to add in much more detail when she eventually revisits the crash. This was not supposed to be the monster that it is, but I severely underestimated the importance this crash was to Canadian aviation investigation and safety.
Part 4 covers the 1994 review, along with the TSB’s early days in aviation, covering up to 1998.
Part 5 starts on Swissair 111 and end on the modern-day TSB.
List of sources from articles used. Mark Kennedy and Michael Tenszen appeared repeatedly in that list, so shoutouts to them.
