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INVESTIGATION
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.
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)
ORGANIZATIONAL DEFICIENCIES
Compromised safety procedures
Excessive un-rectified defects & redundant schedule
Pilots not sufficiently warned on dangers of ice on wings
ORGANIZATIONAL DEFICIENCIES
Inaccurate flight release not reported
Maximum take-off weight exceed
Incorrect fuel figures
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
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
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
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