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ACCIDENT

INVESTIGATION

CASE STUDY AIR ONTARIO FLIGHT 1363


AERODYNAMICS

DEFINITION OF ACCIDENT
a) a person is fatally or seriously injured
b) the aircraft sustains damage or structural failure
which: adversely affects the structural strength,
performance or flight characteristics of the aircraft,
c) Aircraft is missing or is completely inaccessible.

FLIGHT DETAILS OF AIR ONTARIO 1363

Date / Time: March, 10 1989 / 1209 Hours


Location: Dryden Municipal Airport, OH, Canada
Weather condition: Strong winds / Snowy
Crew: Fatalities (3) / Occupants (4)
Passengers: Fatalities (21) / Occupants (65)
Total: Fatalities (24) / Occupants (69)

FLIGHT DETAILS OF AIR ONTARIO 1363

Nature: Domestic Scheduled Passenger


Aircraft / Reg: Fokker F-28 Fellowship 1000 / C-FONF
Total Airframe Hours: 20852
Cycles: 23773
Engines: 2 Rolls Royce Spey 555-15
Crash Site Elevation: 413m (1355 feet)

FACTORS LEADING UP TO CRASH


WEATHER, TECHNICAL ERRORS, OTHER SOURCES

WEATHER CONDITIONS
Constantly deteriorating with low visibility

TECHNICAL ERRORS
Unserviceable APU
Absence of GPU
At least 1 engine required to be running at all times
Otherwise, aircraft cannot startup again
As a result of running engine, no De-Icing carried out

OTHER FACTORS
+10 passengers more weight
Layer of ice on wings gradually building increased
weight
Delay due to Cessna 150 landing (additional 2m45s
ice layer increased on wing)

WHAT HAPPENED SECONDS BEFORE CRASH


WEATHER, TECHNICAL ERRORS, OTHER SOURCES

MINUTES BEFORE DISASTER


During the takeoff:
Captain George John Morwood performed a brief
engine run-up, before releasing the brakes for the
take off roll.
Upon reaching Vr, rotation speed, aircraft lifted off
momentarily and settled back on the runway.

MINUTES BEFORE DISASTER


Following a second rotation, the aircraft managed to
liftoff at 5700 foot of the 6000 foot long runway of
Dryden regional airport.
Aircraft was not able to climb in time, and strike trees
in a nose high attitude.

ANALYSIS (EXTERNAL FACTORS)


ORGANISATIONAL DEFICIENCIES

ORGANIZATIONAL DEFICIENCIES
Compromised safety procedures
Excessive un-rectified defects & redundant schedule
Pilots not sufficiently warned on dangers of ice on wings

Revised forecast not disseminated by SOC


Departed at 11:55am, forecast issued at 11:30am (est)

ORGANIZATIONAL DEFICIENCIES
Inaccurate flight release not reported
Maximum take-off weight exceed
Incorrect fuel figures

Stopover at Dryden Airport for refueling


No ground start facilities; APU not working
De-icing fluid could not be used

ANALYSIS (AERODYNAMIC FACTORS)


STUDY OF THE AIRCRAFT TYPES AERODYNAMICS

AERODYNAMIC FACTORS
F- 28 designed for cruise @ M0.75 and high max lift
coefficient at low speed.
Large wing & nose radius minimizes separation
under high lift conditions (stall from trailing edge)

AERODYNAMIC FACTORS
Stall fence located at forward midsection of wing.
Stall spreads outwards from leading-edge fence
location in fan-shaped manner toward wing-tip and
wing root region.

AERODYNAMIC FACTORS
Since ailerons are near wing tip, stall lasts, but
lateral control is still possible
Due to wing fences, air flow into engines remain
smooth to high angles of attack.

AERODYNAMIC FACTORS
Wind tunnel testing by Fokker Aircraft. Artificial
roughness (icing) causes premature stall with
boundary layer separation all along leading edge.
At flaps 30, wing stalled at AOA 7 degrees lower than
clean wing showing 33% loss of C L max.

ANALYSIS (ICING)
DIFFERENT TYPES OF ICING & HOW IT CAUSED FLIGHT 1363 CRASH

AT NORMAL CONDITION
With a smooth airfoil, airflow over the wings would be
undisturbed

Air flows smoothly over the wings, and the aircraft gets its
required lift

AT NORMAL CONDITION

HOW ICING AFFECTED FLIGHT 1363


With the obstruction at the leading edge, air is unable to flow
over and under the airfoil smoothly

So this happens..

AT ICING CONDITION

LESSONS LEARNT
Summary of Accident Investigation & Actions by FAA

SUMMARY
Pilots reduced awareness of his aircrafts external state
once settled in the cockpit
Present automatic ice detection systems designed to
detect and warn against the accretion of ice in flight
rather than and not while on ground

SUMMARY
Lack of sufficient information, advice and direction in Air
Ontarios FOM regarding aircraft ground de-icing and
for operations from contaminated runways
No operating manual made available onboard for pilots
to react to the wing contamination that degraded the
flight performance

ACTIONS TAKEN BY FAA


To reduce icing-related incidents (relatable actions):
1999: FAA issued an Airworthiness Directive - mandated
revisions to AFM (advise flight crews to activate airframe
pneumatic de-icing boots - first sign of ice accumulation
August 8, 2007: FAA final rule introduced new airworthiness
standards for the performance and handling characteristics of
transport airplanes in icing conditions improves level of safety

QUESTIONS?

REFERENCES

Aviation Safety Network. (n.d.). ASN Aircraft accident Fokker F-28 Fellowship 1000 CFONF Dryden Municipal Airport, ON (YHD). Retrieved from http://aviationsafety.net/database/record.php?id=19890310-1

Federal Aviation Administration. (n.d.). Fact Sheet Flying In Icing Conditions.


Retrieved January 24, 2015, from http://www.faa.gov/news/fact_sheets/news_story.cfm?
newsid=10398

Federal Aviation Administration. (n.d.). Lessons Learned. Retrieved from


http://lessonslearned.faa.gov/ll_main.cfm?TabID=1&LLID=31

Moshansky, V. P. (1992). Commission of Inquiry into the Air Ontario Crash at Dryden,
Ontario (Canada). Retrieved from http://epe.lac-bac.gc.ca/100/200/301/pcobcp/commissions-ef/moshansky1992-eng/moshansky1992-eng.htm

SKYbrary Aviation Safety. (n.d.). Accident. Retrieved January 24, 2015, from
http://www.skybrary.aero/index.php/Accident