Investigation Summary
The accident was the result of a complex chain of operational failures. The aircraft had been dispatched with an inoperative APU, a condition that had persisted for five days. Upon landing at Dryden, where no external power unit was available, the crew performed a hot refuel (refueling with an engine running) to ensure they could restart the second engine. To maintain a safe distance from the refueling operations on the right wing, the crew kept the port (left) engine running. During this time, heavy snow accumulated on the wings. The crew faced a dilemma: they could not deice with the engines running due to the risk of toxic fumes entering the cabin, but they could not shut down the engines without grounding the flight. Under pressure to maintain the schedule and influenced by ambiguous company manuals, the crew elected to take off without deicing. The F28, which is highly sensitive to wing contamination, failed to achieve sufficient lift, settling back onto the runway before finally lifting off near the end of the strip and striking trees 3,156 feet past the runway threshold.
Final Conclusions
The Commission of Inquiry, led by Justice Virgil P. Moshansky, concluded that while the Captain bore responsibility for the final decision to take off, the broader aviation system failed the crew. The report cited competitive pressures from deregulation, inadequate training manuals regarding the F28's sensitivity to ice, and the airline's failure to provide proper ground support equipment at Dryden. The investigation concluded that the air transportation system failed the Captain by allowing him to be placed in a situation where he did not have all the necessary tools that should have supported him in making the proper decision. The investigation also criticized Transport Canada for oversight deficiencies during Air Ontario's expansion into jet operations.
Video Analysis
No video analysis linked for this case file yet.
Airframe & Maintenance
Crew Experience
Captain
George Morwood, age 52. Fatal. Veteran pilot but new to the F28.
First Officer
Keith Mills, age 35. Fatal. Had fewer than 150 hours on the F28.
Systems & Failure Modes
Auxiliary Power Unit (APU)
A small internal engine used to provide electrical power and bleed air for engine starting. Its failure forced the crew to keep a main engine running on the ground.
Wing Aerodynamics
The F28-1000 lacks leading-edge slats; even a thin layer of frost or snow can significantly increase stall speed and reduce lift.
Deicing System
Ground deicing was required, but procedures prohibited its use while engines were running due to the risk of ingesting glycol fumes into the air conditioning system.
Interesting Facts
- 01The aircraft was manufactured in 1972 and had previously served with Turkish Airlines.
- 02The Fokker F28 is a 'hard wing' aircraft, meaning it has no leading-edge slats, making it extremely sensitive to ice contamination.
- 03Both the Cockpit Voice Recorder (CVR) and Flight Data Recorder (FDR) were too badly damaged by the post-crash fire to be read.
- 04The investigation led to the dissolution of the Canadian Aviation Safety Board (CASB) and the creation of the Transportation Safety Board of Canada (TSB).
- 05Both pilots were relatively new to the Fokker F28, having flown fewer than 150 hours combined on the aircraft type.
Safety Actions & Advisories
Clean Wing Concept
Strict enforcement of the 'clean wing' principle, requiring that no aircraft take off with any frost, ice, or snow adhering to critical surfaces.
Type II Deicing Fluid
Increased adoption and regulation of Type II deicing fluids, which contain thickening agents to provide longer holdover times.
Investigative Reform
The Canadian government replaced the CASB with the Transportation Safety Board of Canada (TSB) to ensure greater investigative independence and a multi-modal approach.
Ground Operational Procedures
New regulations were established regarding the safety of 'hot refueling' (refueling with engines running) and the coordination between flight crews and ground deicing personnel.
Training and Manual Standardization
Mandatory improvements to pilot training and manuals specifically addressing the aerodynamic sensitivity of 'hard wing' aircraft like the Fokker F28 to wing contamination.
Known Controversies & Unanswered Questions
CASB Internal Conflict
Reference ↗The investigation occurred during a period of severe internal division within the Canadian Aviation Safety Board following the Arrow Air Flight 1285R crash, which contributed to the board's eventual dissolution.