The aircraft, a Fokker F28-1000, had been manufactured in 1972 and had been in service since 1973. The aircraft had been used by Air Ontario since November 1987. It was one of two F28-1000s operated by the airline. The flight was under the command of veteran pilot Captain George John Morwood. He was an experienced airman who had been flying for approximately 34 years. He had roughly 24,100 flying hours. His first officer was Keith Mills. Mills was also a highly experienced pilot, having accrued more than 10,000 hours of flying time. Both pilots were new to the F28-1000, having fewer than 150 hours between them on the aircraft type.
Accident
The flight had departed from Thunder Bay bound for Winnipeg with an intermediate stop in Dryden where the aircraft struck trees shortly after takeoff and then disintegrated on impact, causing the deaths of 21 of the 65 passengers and 3 of the 4 crew members on board, including both pilots.
Investigation
The fierce post-crash fire resulted in severe damage to both the Cockpit Voice Recorder and the Flight Data Recorder; neither of these units could be read as a result. Because of this, the investigative effort relied almost entirely on witness statements regarding the crash and the events leading up to it. The investigation revealed that an unserviceable auxiliary power unit, and no available external power unit at Dryden Regional Airport, led to questionable decision-making which was a critical factor leading to the crash of Flight 1363. If the engines had been turned off, they could not have been restarted again due to the unserviceability of the APU and lack of external power. Therefore, the port engine was left running during the stopover in Dryden. Snow was falling gently that afternoon and a layer of 0.6 to 1.3 centimetres of snow had accumulated on the wings. The wings needed to be de-iced before takeoff, but the Fokker F28 aircraft is never supposed to be de-iced while the engines are running because of a risk of toxic fumes entering the cabin of the aircraft. The pilot therefore did not request to have the wings de-iced; at the time, airline instructions were unclear on this point but the subsequent report was very critical of this decision. Fuel needed to be loaded and was done with the engine running while passengers were on board. Off-loading and reloading passengers would have taken considerable time and the longer the aircraft stayed on the ground the greater was the need for the wings to be sprayed with de-icing fluid. To prevent further delay and a greater possibility of a buildup on the wings, the pilot, Captain Morwood, decided to have the aircraft fuelled while the engine was running and with passengers on board. This procedure was not then, and is not now, prohibited by Transport Canada. Airline instructions were also inconsistent.
Result
The accident investigation was subsumed into a judicial inquiry under the Honourable Virgil P. Moshansky. His report showed that competitive pressures caused by commercial deregulation cut into safety standards and that many of the industry's sloppy practices and questionable procedures placed the pilot in a very difficult situation. The report also stated that the aircraft should not have been scheduled to refuel at an airport which did not have proper equipment and that neither training nor manuals had sufficiently warned the pilot of the dangers of ice on the wings. Moshansky blamed Transport Canada for letting Air Ontario expand into the operation of bigger, more complicated aircraft without detecting the deficiencies of their existing aircraft. After the crash of Air Ontario Flight 1363, many significant changes were made to the Canadian Aviation Regulations. These included new procedures regarding re-fuelling and de-icing as well as many new regulations intended to improve the general safety of all future flights in Canada. Specifically these referred to the effectiveness of certain deicing fluids over time and the increased use of Type II fluid. This mixture includes polymerising agents, which make the deicing effect last longer.
