Author Martin B Aubury January 1993; On 10 March 1989 an Air Ontario Fokker F28 crashed just after take-off from Dryden Ontario with the loss of 24 lives.  The pilot attempted the take-off with ice on the aircraft wings.  Why he had done so became the subject of a vast judicial inquiry that delved deeply into the contributing factors which arose from commercial pressures and inadequate safety surveillance.

"The aircraft was hitting trees, hitting trees, and at that point the aircraft I guess was decelerating and we were inside the blender effect... you take a blender, throw in some metal, some trees, people and turn it on."  So ended Air Ontario flight 1363 in March 1989.  So ended Canada's delusion that the country could have cheap, deregulated air fares without the need for extra air safety surveillance.  

The Air Ontario Fokker F28 aircraft crashed immediately after take-off from Dryden Municipal Airport.  A routine accident investigation soon found that the aircraft had been unable to gain height because its wings were covered in ice and snow.  The pilot should have known that the aircraft could not fly in this condition.  When investigators looked at why the pilot had attempted a take off, it became apparent that the real causes of the accident lay at the heart of deregulation and that because of deregulation, traditional air safety standards had been cut.

The accident was all the more tragic because just seven weeks earlier, warnings within the regulatory authority Transport Canada had been leaked to the press.  In part the leaked memo said, "Air carrier inspection is no longer capable of meeting even minimum requirements necessary to ensure safety.  In fact, it is no longer able to assure the Minister of the safety of large air carrier commercial air services in Canada".  It went on with the ominous warning, "The situation is to the point where every ACI (Air Carrier Inspector) and an increasing number of industry pilots are convinced that a major accident is inevitable".

The routine accident investigation was subsumed into a judicial inquiry under the Honorable Virgil P. Moshansky.  His report clearly shows that competitive pressures caused by commercial deregulation cut into safety standards. Moreover the regulatory authority was aware of this but could not counter it because the government was cutting regulatory resources.

The two government policies of commercial deregulation of the airlines and fiscal restraint on federal government services together, were a recipe for disaster.  Unfortunately it is a recipe which is being repeated in Australia.

Economic deregulation of the airlines started in the USA in 1978, Canada followed in 1984.  In December 1985 the Canadian House of Commons Transport Committee was warned that competitive pressures would erode self policing by the industry of its safety standards.  At the same time Transport Canada arranged a number of visits to the USA to learn from their experience of deregulation.

To counter safety problems arising from deregulation the US authority eventually had to double its safety surveillance staff.  Some of the Canadians knew that they too needed more resources but their pleas fell on deaf ears.

A report by the Director of Licensing and Certification outlined the problems confronting US authorities. It listed more than 50 areas of concern including:
 -  rapid expansion of airlines into unfamiliar areas of operation
 -  inexperienced, unqualified and/or over extended management
 -  incomplete or inaccurate records
 -  non-compliance with approved procedures
 -  increased contracting out of training and maintenance
 -  use of unauthorized or improperly trained maintenance personnel
 -  improper/inaccurate control of aircraft weight and balance

The report was prophetic in predicting the factors which later contributed to the Air Ontario accident.

Air Ontario Inc. was formed by the merger of Air Ontario Limited and Austin Airways.  Under the impetus of deregulation it changed from being mainly a charter and cargo operation with a mix of generally small aircraft, to become a feeder airline for the large national carrier Air Canada.  Air Canada effectively owned Air Ontario and wanted to project its corporate image through its subsidiary by way of marketing, logo and decor.  Unbeknown to passengers Air Canada deliberately distanced itself from operational and airworthiness aspects of Air Ontario.

Similar deceptions are prevalent in Australia.

The judicial inquiry found that Air Ontario had rushed the introduction of its relatively large and complicated jet powered F28.  Some personnel were not properly trained and some manuals and procedures were neither correct nor consistent.  These deficiencies were not fully detected nor were they countered by a regulatory authority which was hopelessly under resourced.

On the day of the accident the aircraft was flying shuttle services from Thunder Bay to Winnipeg via Dryden.  It was a Friday at the start of school holidays so the aircraft was full.  This limited the amount of fuel which could be carried on any one leg of the journey without exceeding the maximum allowable weight of the aircraft.  Also the weather was inclement and getting worse, so the aircraft needed to carry enough fuel for a longer than normal diversion.  These factors combined to force the airline to schedule refueling during the aircraft's second stop at Dryden.

The aircraft had many unrectified defects. The one which became critical to the accident was an unserviceable Auxiliary Power Unit (APU). This is a small extra engine in the rear of the aircraft which among other functions provides compressed air to start the main engines.  The main engines can also be started by an external power supply.

The airline put the pilot in a very difficult predicament when he landed at Dryden.  It was not normal to refuel at Dryden.  At Dryden there were no ground start facilities so the aircraft was dependent on its APU but the APU was not working.  If the pilot stopped the engines he could not start them again. He needed to load fuel but this should never be done with engines running and certainly not with passengers on board.  Snow was falling gently.  Off-loading and reloading passengers took time and the longer the aircraft stayed on the ground the greater was the need for the wings to be sprayed with deicing fluid.  On the Fokker F28 aircraft deicing fluid must not be applied while the engines are running.

The pilot had the aircraft fueled while the engines were running and with passengers on board.  Although this is a very dubious procedure it was not then prohibited by Transport Canada and airline instructions were inconsistent.  The pilot did not have the wings deiced; again airline instructions were unclear on this point.

With ice on the wings, the wings did not lift properly during take off.  The aircraft staggered into the air and crashed just beyond the end of the runway.  24 of the 69 people on board were killed.

The pilot died in the accident and in times gone by the accident would have been dismissed as "pilot error".  Now, because aircraft accidents are so horrendously expensive for society, society asks what led the pilot to make his mistake.

Commissioner Moshansky found that the aircraft was operating with an excessive number of unrectified defects, that the aircraft should not have been scheduled to refuel at an airport which did not have proper equipment and that neither training nor manuals had sufficiently warned the pilot of the dangers of ice on the wings.  Moshansky blamed Transport Canada for letting Air Ontario expand into operation of bigger, more complicated aircraft without detecting the deficiencies.

Most importantly Moshansky expressed concern that the Government had not appreciated the safety implications of embarking on a policy of promoting increased airline competition at the same time as it was imposing a freeze on safety regulation resources.

Nearly two hundred recommendations arose from the Air Ontario accident but two capture the tenor of the report.

"Transport Canada (should)put in place a policy directive that if resource levels are insufficient to support a regulatory or other program having a direct bearing on aviation safety, the resource shortfall and its impact be communicated without delay to successively higher levels of Transport Canada management until the problem is resolved or until it is communicated to the Minister of Transport".

The Australian Government is still deluding itself that it can trust a deregulated industry to maintain standards and that a strong air safety authority is an expensive luxury.  From the Board of the Civil Aviation Authority down, those who accept that a 40% cut in resources has no effect on safety are lauded and promoted. Those who disagree have been ousted.

"Transport Canada establish a mandatory education program to ensure that senior managers and officials of the department who are responsible for or associated with aviation programs are aware of the basis for and the requirement to support policies that affect aviation safety".

How sad that this should be necessary.  In Australia, from the Chief Executive of the CAA down, seasoned bureaucrats have been replaced with "agents of change" who adhere to the "right" corporate ethos.  From airworthiness, the head of airworthiness, the head of maintenance, the head of training, the head of aircraft certification, the head of aircraft structures and the head of aircraft fatigue have all left.

Canada has suffered a number of air disasters and several resulted in formal inquiries akin to that undertaken by Commissioner Moshansky.  When the findings of an earlier Royal Commission by Justice Dubin were reviewed by Australian airworthiness specialists they were gratified to see that virtually all of Dubin's recommendations with regard to aircraft safety were already in place in Australia.  Ten years later we should be alarmed at how many of the criticisms and recommendations arising from the Air Ontario accident apply in Australia.

We should be most alarmed because, as happened in Canada, our Government is not funding sufficient surveillance resources to keep the industry honest.

Published in Canberra Times, 7 January 1993 and reproduced with permission of the author Martin B Aubury

Author’s Post Script – Within two years Australia suffered several air crashes that led to Parliamentary and judicial inquiries.  These inquiries found that deregulation in Australia had caused exactly the same irregularities as happened earlier in Canada and the USA.