Air Ontario Flight 1363

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 (APU), 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, thus grounding the aircraft until an external power cart could be flown in from Winnipeg the next day. 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 cm of snow had accumulated on the wings. The wings needed to be deiced before takeoff, but the Fokker F28 aircraft is never supposed to be deiced 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 deiced; 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 (known as a hot refuel). 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 deicing fluid. To prevent further delay and a greater possibility of a buildup on the wings, Captain Morwood decided to have the aircraft fueled 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.