"Air Ontario Flight 1363 was an Air Ontario flight of a Fokker F28-1000 Fellowship which crashed near Dryden, Ontario on March 10, 1989 immediately after take-off en route from Thunder Bay to Winnipeg via Dryden. The aircraft crashed after only 15 seconds because it was not able to achieve enough altitude to clear the trees beyond the end of the runway due to ice and snow on the wings and overloading with ten more passengers (Moshanshy, 1992). Meanwhile, some victims were unable to escape because of the inoperative Auxilliary Power Unit (APU) which is supposed to provide electrical power for the emergancy lighting (Moshanshy, 1992). Attributed to the crash and the resulting fire, one-third out of the 69 people on board died (Moshanshy, 1992).
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1) Flight Crew Situation Awareness
In a flight crew, pilots are suppose to act together to make decisions and achieve an ultimate goal. They are to take into consideration, their surroundings and activities occurring around them to make a sound and safe judgement.In the case for Air Ontario Flight 1363, the pilots failed to consider the amount of snow fall and the possibility of icing. While stationary on the ground, 0.6 to 1.3cm of snow had accumulated on their wings and a decision to de-ice should have been made. However, as mentioned in the investigation, commercial pressure to be on time clouded the Flight Crew's Situational Awareness. Also, the pilots were aware that most of the passengers had connecting flights, thus a rash decision was made to take-off without de-icing.
2) Organizational Error
In 1989, Dryden Regional Airport was limited in its facilities. As mentioned by the report, the Fokker was the first of its kind to fly to Dryden which was better suited for General Aviation Aircrafts (GAA). Therefore, the organization should never made the decision for aircrafts to refuel at Dryden.
Furthermore, it was noted in the investigations that there were no manuals and insufficient training given to the pilots about de-icing. Therefore, the pilots were not able to make a good assessment on the weather.
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- Air Ontario flight 1363
- This Wikipedia page provides more details about this occurrence.