I note a few references to the crash of Air Ontario Flight 1363, a Fokker F28 which crashed into a forest less than a kilometer from the end of the runway at Dryden Ontario in 1989. The accident resulted in 24 fatalities, including both of the flight deck crew and the senior flight attendant. There were 45 survivors, including a second flight attendant.
Subsequent to the accident and the official accident report the government formed a Commission of Inquiry chaired by the Honourable Vincent Mashansky to examine not just the immediate cause of the accident (which was unquestionably the decision of the pilot to depart the runway with snow-contaminated wings) but also all of the causal factors which may have influenced the captain’s unfortunate decision to attempt the takeoff, given that he had a reputation for being cautious and responsible (although this may have contributed to his decision, inasmuch as he no doubt also felt a responsibility to get his passengers to their destination, particularly as it was the start of a school break and many passengers were to connect to flights which would take them to vacation destinations).
Justice Mashansky’s 1,300 page report is very comprehensive. It could serve as a textbook example of how all of the holes can line up, insofar as the Commission found that virtually everyone having anything to do with Flight 1363 and this aircraft made errors or omissions which individually might be deemed insignificant but collectively led to a smoking hole in the ground. (To be clear, the interpretation that the errors might be deemed insignificant is mine alone… Mashansky was less forgiving). These factors included the ground worker who fueled the craft but failed to bring the snow on the wing to the captain’s attention, and the senior flight attendant who dismissed the concerns expressed by a nervous passenger, as well as the junior attendant who deferred to the judgement and authority of her senior colleague.
Perhaps most relevant to this discussion the Commission examined the responses of two surviving passengers… an off-duty Air Ontario Dash 8 captain and an off-duty Air Canada DC9 captain. One of these testified that he
knew that the aircraft would not fly (emphasis mine) but presumed that the captain knew this too. In any case, he testified that he presumed that the captain planned to monitor the snow on the wings during the takeoff roll and would abort the takeoff once he saw that the snow was adhering to the wing. According to the testimony of others this method of determining wing contamination during the takeoff roll was not entirely uncommon at Air Ontario (which had evolved from Austin Airways, flying DC3 and Otters around northern Canada) and if I recall correctly Justice Mashansky (a pilot himself) found this practice to be unsatisfactory to say the least. We can be certain that the regulations drafted subsequent to this accident were not intended to allow pilots to make their determination of whether snow and ice were “adhering” when they were halfway down the runway approaching V1.
It’s nice to see that many on this board say that they would have… had they been passengers… prevented the takeoff attempt. However, in this context it ought to be noted that the other off-duty captain was also aware of the condition of the wing, but felt that professional courtesy and respect required that he remain silent. The two passenger-pilots had something like 18,000 hours experience between them while the two at the pointy end had something like 130 hours of combined experience (on type).
I recognize that this report is now twenty years old and we now have a greater appreciation of human dynamics (if only because of subsequent incidents and accidents). Taken as a whole the report was (and remains) a damning indictment of the airline`s owners and managers (largely one and the same) and Air Canada (Air Ontario`s code-share partner and part-owner at the time). Ultimately, of course, the report infers that industry deregulation in the absence of adequate regulatory authority created an environment which contributed to the accident. Mashansky made 191 recommendations, and while I believe that some were acted upon I’ve a hunch that most were not. Indeed, something like 18 months after the release of the report another F28 (USAir 405) crashed at LaGuardia under similar circumstances.
I presume, of course, that I am preaching to the choir here. In fact, I hope that I am.
And I apologize to those who I've offended, given that... well, my username says much. Indeed, I was going to keep my thoughts to myself until I realized that I am one of those people who would keep my thoughts to myself even if there was a foot of snow on a wing.
Apologies for being so long-winded, and mods feel free to edit.
The full text of the report can be found here:
Commissions of Inquiry
Also, there is an episode of “Air Crash Investigation” devoted to the accident and Mashanky’s report here: