Air Ontario Flight 1363 - Investigation

Investigation

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 were critical factors leading to the crash of Flight 1363. If the engines had been turned off, they could not be restarted again due to the unservicibility 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 F-28 aircraft is never supposed to be de-iced while the engines are running due to the risk of toxic fumes getting into 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 (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 de-icing fluid. In order to prevent further delay and greater possibility for build up on the wings, the pilot, Captain George John Morwood, decided to have the aircraft fuelled while the engine was running and with passengers on board. Although this is a very dubious procedure, it was not then, and still is not, prohibited by Transport Canada. Airline instructions were also inconsistent.