Air ontario Flight 1363 and Safety Management

1. Executive Summary

This report discussed the major deficiencies of Air Ontario 1363 based on the Moshansky Report and the deficiencies are categorized into flight operational aspect, maintenance aspect and the operational aspect. Measures on how deficiencies could be discovered and rectified are discussed based on the foundation of the ICAO Safety Management System.

2. Introduction

On 10th March 1989, a tragic flight accident, Air Ontario flight 1363, occurred in Dryden Ontario, Canada. Of the sixty-nine people on the Fokker 28 aircraft (C-FONT), twenty-four people died including the Captain and First Officer. The initial schedule of the flight 1363 was originally from Thunder Bay, Ontario to Winnipeg, Manitoba and stopped over at Dryden for refueling. The misadventure took place in the sector from Dryden to Winnipeg. The late arrival from Thunder Bay had delayed the departure to Winnipeg and an emergency landing of a Cessna 150 even postponed the flight. With the deteriorating weather, the Fokker 28 crashed 950 meters west of the runway 29 in the bush.

This report identified the deficiencies before the crash in flight operation, maintenance and operation aspect based on the Virgil Moshansky Report concerning the Air Ontario 1363 incident. Ways to prevent and mitigate the hazards leading to the crash in relation to the Safety Management System are discussed. With the SMS properly adopted, the Dryden accident could have been prevented.

3        Deficiencies of Air Ontario Flight 1363

3.1        Flight Operations Deficiencies

3.1.1         Inexperienced Dispatcher and Erroneous Flight   release

The flight dispatcher ,Mr. Daniel Lavery showed inability to perform the job by failing to associate freezing rain with de-icing process whereas another flight dispatcher ,Mr. Wayne Copeland who was more experienced had not revised the weather forecast of Dryden airport. If he had noticed the freezing weather, the SOC duty manager would have been informed and overflying Dryden should be the selection instead of stopping for refuel.  

The erroneous flight release information includes maximum take off weight (MTOW), fuel data and the excess payload. The mistaken flight release was exceptionally adopted and not revised by Captain Morwood.

If SMS is properly in place, under the section of safety risk management, hazard like subpar dispatchers could be identified through audits. Auditors rated the performance and competency of the flight dispatchers by using a standardized observation and checklist. The inability of dispatchers calculating the F-28 payload and maximum take off weight could have been discovered(ICAO,2013).

Negligent dispatchers would have undergone professional training after the hazard assessment. Air Ontario dispatchers commenced their duty after one or two weeks training. Both Mr. Lavery and Mr. Copeland had only one to two weeks dispatcher training and they received no F-28 manual training. The training as a dispatcher should reach a standard duration, like a two months course and on-the-job training. Training schedule and content should be formal and documented. Apart from their specified knowledge regarding their post, their safety roles and responsibility should be clearly delineated. With adept dispatchers, the Captain could have received the accurate flight release that provided the pilot with necessary context to make an informed decision(ICAO,2013).