CONFIDENCE IN THE GOVERNMENT’S ABILITY TO HELP PREVENT AIR DISASTERS IS CLEARLY SHAKEN
GREG W. TAYLORJuly311989
There was little in the still, warm air of the woodland glade to suggest that it had ever been the scene of terror, fire and violent death. Knee-deep in wild blueberry bushes, Alberta Court of Queen’s Bench Judge Virgil Moshansky surveyed the torn stumps of trees and scattered bits of wreckage, all that remained last week of the event that had brought him to the hillside clearing outside Dryden, Ont., 300 km northwest of Thunder Bay. It was a scene in sharp contrast to the day last March when an Air Ontario Fokker F-28 jet lifted briefly from the end of a runway at Dryden’s nearby airport, wavered momentarily in a veil of snow, then crashed and burned on the slope where Moshansky stood. Twenty-four people died in the disaster, while, miraculously, 45 others survived. Moshansky’s purpose in visiting the site of the tragedy was to begin the work of finding out why the accident happened—and to recommend ways to prevent anything like it from happening again.
For veteran observers of Canada’s troubled aviation safety bureaucracy, however, Moshansky’s mission was layered with significant ironies. For one thing, the Dryden crash bore eerie echoes of the country’s worst-ever air disaster 39 months earlier: the crash on takeoff of a heavily loaded and ice-laden DC-8 jet from Gander airport in Newfoundland in December, 1985, in which 256 people died. And, for another, in large part because of that earlier disaster, the Moshansky inquiry marked the first time in 20 years in Canada that primary responsibility for an air crash investigation had been given to a royal commission headed by a jurist.
In the wake of the Gander crash, the nine-member Canadian Aviation Safety Board (CASB)—then responsible for the investigation of air accidents—had broken into warring camps with dissenting views of what caused the Newfoundland tragedy. With public confidence in the government’s ability to explain—and help prevent—air disasters clearly shaken, federal Minister of Transport Benoît Bouchard in March ordered the CASB replaced, commissioned a review of its Gander investigation and entrusted the inquiry into the Dryden accident to Moshansky. Last week, as the judge began his task, officials in Bouchard’s department were putting the final touches on a plan to reduce congestion over Toronto’s overburdened Pearson International Airport. But in the week’s final irony, former Supreme Court justice Willard Estey on Friday issued his report on the board’s Gander inquiry. The findings did little either to confirm or discredit the agency’s earlier conclusions but they provoked outrage from families of the U.S. victims.
Despite Bouchard’s actions, Canadian air travellers clearly remain nervous. A poll by Gallup Canada Inc. released in April found that 69 per cent of Canadians believed air travel had become less safe in the previous five years. In its analysis of that finding, Gallup concluded that both the Gander and Dryden crashes, as well as regular reports of “near-misses” between aircraft and the highly publicized disputes at the CASB, “have served to upset the Canadian air-travelling public.” Those concerns were underscored last week when the crash of a Philippine Airline BAC-1-11 jet landing at Manila killed eight persons and more than 100 perished in the crash of a United Airlines DC-10 in Sioux City, Iowa (page 24).
By the time Moshansky’s inquiry into the Dryden crash began last week, many details about the final minutes of Air Ontario’s Flight 363 had already been established. It was snowing lightly and the temperature hovered around freezing at 11:40 a.m. on March 10 when the twin-engined Fokker landed at Dryden’s small municipal airport half an hour behind schedule on its run from Thunder Bay to Winnipeg. Twenty minutes later, refuelled and fully loaded with 65 passengers—most from around Thunder Bay—and four crew members on board, the aircraft was ready to leave. By then, the snow had turned wet and was falling heavily. Capt. George Morwood turned down an offer to have his aircraft deiced, a procedure that would have taken only a few minutes but would have required him to shut down the plane’s engines. At 12:03 p.m., the jet had to wait six more minutes while a smaller aircraft landed to escape the worsening weather. At 12:09, the Air Ontario plane began its takeoff run.
As Craig Brown, a 23-year-old small-plane pilot, watched, the red-and-white aircraft lumbered down Dryden’s 1,800-m runway. To Brown, the jet appeared to use several hundred metres more runway than normal before its nose lifted into the air. Then, Brown recalled last week, “as it passed over the trees, the left wing dipped, then it came back up. Then the right wing started to drop and [the pilot] brought it back again. It seemed like he was fighting it. Then it disappeared in the trees.” Moments later, black smoke and flames billowed above the trees. Arriving at the crash scene within minutes, Brown found dazed survivors, some badly burned and injured, struggling through hip-deep snow away from the shattered aircraft. Other victims remained trapped, screaming inside the burning fuselage.
Four months later, Moshansky listened carefully to Brown's chilling account in the narrow, pine-walled meeting room of Dryden’s Best Western Motor Inn, as his inquiry moved indoors to begin piecing together the details of the crash. A more contentious perspective on the disaster came from Dryden airport manager Peter Louttit. An ex-CF-100 fighter-jet pilot, Louttit recalled being disturbed when he heard “an explosion” from one of the Air Ontario jet’s engines just before the plane rolled out of sight from his office window. He told Moshansky that he was convinced the sound was the result of an engine failure—called a “flameout” by pilots. When cross-examined later on the point, however, Louttit acknowledged that he had no proof a flameout had occurred.
While each witness shed some light on the tragedy, much more remained elusive. The aircraft’s flight recording—contained in the so-called black box—was destroyed in the intense heat of the fire that followed the crash and yielded no useful information. And one longtime pilot who attended the hearings, but who refused to be identified, warned against the conclusion that ice accumulation on the Fokker’s wings was the only cause of the disaster. “Accidents are the result of a series of things,” he said. “Only a bomb is the sole reason for a plane crash.” But while Moshansky continued his sifting of the record of Flight 363’s tragic conclusions, the similarities between that disaster and the 1985 crash in Gander of an aged Arrow Air charter DC-8 became increasingly evident. In both cases, heavily loaded jet aircraft crashed into the woods shortly after takeoff in conditions that could have caused icing problems. In both cases, some observers believed an engine malfunction just before or during takeoff may have been a contributing cause.
The legacy of the Gander crash, however, has extended beyond its tragic impact on the families of its victims—most of them U.S. servicemen returning home from peacekeeping duty in the Middle East. For three years after the 1985 disaster, a team of specialized CASB investigators conducted sophisticated tests on the wreckage of the Arrow Air jet, questioned witnesses and examined flight and airline documents. Last December, the board released its conclusions, reporting that the most significant cause of the crash was a sandpaper-thin coating of ice on the big jet’s wings that had reduced the plane’s capacity to lift off.
But a second, minority report, released on the same day by four dissenting board members with the endorsement of several senior transport department officials, immediately undermined the official version. The dissenters argued that there was evidence of engine failure, an explosion—and perhaps even a bomb—any of which could have brought the jet down. Within days, the public disagreement between the two factions of the CASB was made worse by a leaked Transport Canada report criticizing both sides in the issue. That document suggested that a deeper issue lay at the heart of the dispute—that the aviation safety board was riven by disagreement about whether investigations should be under the control of professional accident investigators or the CASB board members.
With the Air Ontario jet’s crash three months later, a beleaguered Bouchard, who had tried unsuccessfully to end the bureaucratic in-fighting between the CASB and its staff, was forced to take more dramatic action. On March 29, Bouchard announced wholesale changes in his department. Among them:
• Bouchard stripped the CASB of the power to rule on the cause of air crashes and ordered it replaced by a new agency to investigate all types of transportation accidents;
• a task force was promised to conduct a review of air safety issues, including the shortage of safety inspectors and air traffic controllers, and all air traffic and safety regulations;
• the investigation of the Dryden accident was turned over to Moshansky, while Estey was assigned to review the CASB’s investigation of the Gander crash.
As it turned out, Estey’s review found little support for the CASB dissenters’ position. Wrote Estey: “There is almost no evidence which supports any of the conclusions of the minority.” But his report held no comfort either for the CASB majority or any observers who had hoped that investigators might draw some lessons from the tragic finale to Arrow Air Flight 950. Declaring that the cause of the crash remained a mystery, Estey said specifically that the evidence “does not show that ice was the cause of the accident.” Relatives of the crash victims rejected the finding and called for a separate, U.S. investigation and the release of a censored FBI report on the crash.
Still, it was evident last week that Bouchard’s reforms have indeed reshaped the way air crashes are investigated in Canada. Frederick von Veh, Moshansky’s chief commission counsel, said that the inquiry had “experimented” with an approach very different from past inquiries. Although von Veh complimented the CASB’s investigators and their technical facilities in Ottawa as among “the best in the world,” he added that they had become too self-reliant. As a result, he said, the Moshansky inquiry would “bring in expertise from outside,” including Air Ontario officials, the Canadian Airline Pilots’ Association and police investigators. In another departure from past practice, Moshansky planned to hear from representatives of the victims of the crash, including survivors and their families.
Moshansky’s mandate calls for a progress report by the end of September and the final report no later than March 30, 1990. Along the way, technical reports on the aircraft and its engines should shed more light on Louttit’s flameout theory. The inquiry will also examine the significance of a Transport Canada audit of Air Ontario’s operations, completed in February, 1988, that identified 410 shortcomings in the airline’s compliance with transport department regulations. And for the specialists preparing those reports, there is an additional pressure. Many are former employees of the CASB, whose examination of the events of last March 10 will have a direct bearing on the confidence of Canadian travellers and their profession’s tarnished reputation.
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