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SAFETY SENSE RULES AND REGULATIONS siderable flying experience both pilots were new to swept-wing, high perfor- TO SERVE AND TO PLEASE mance turbojet aircraft. By Michael R. Grüninger and Markus Kohler of Great Circle Services AG (GCS) Fast Growth at Air Ontario Air Ontario had been established through a merger only two years before the Dryden accident. Air Ontario experienced rapid growth after the merger and aimed to be the leading regional carrier in Canada. To achieve this goal the airline was re- equipping and modernizing its fleet and investing in state-of-the-art tech- nology such as the F-28, a modern, swept-wing, and turbojet aircraft. Unfortunately, the project plan to introduce this aircraft in the Air Ontario operation failed to adequately take into account the complexities of introducing a modern, swept wing jet into a regional airline with a mainly turbo-prop, straight wing fleet. The air- ir Ontario Flight 1363 started the Due to the inoperative APU the crew line failed to recruit pilots and man- take-off roll on a snow-covered had planned to carry additional fuel to agers with jet aircraft experience, A runway at Dryden Regional avoid uplifting fuel in Dryden. But although they had intended to do so. Airport, Ontario, for the flight to operations control added some pas- This in turn lead to several shortcom- Winnipeg, Manitoba in March 1989. sengers on the flight into Dryden and ings in the preparation phase; flight The Fokker F-28-1000 Fellowship had the crew could not through-tankage. procedures were not established, the four crew and 65 passengers on board. To avoid excessive uplifts in Dryden, pilot training syllabus was not devel- The aircraft had not been de-iced prior where the fuel was more expensive, oped, the Aircraft Operating Manual to departure. During take-off the cap- the crew took as much fuel as possi- was not established, a sufficient spare tain initiated rotation. But the aircraft ble. The flight in cold air temperature parts inventory was not procured, would not fly, and settled back on the cooled the high amount of fuel carried flight planning and performance calcu- runway. After a second rotation the into Dryden and when the aircraft lations were not adequately prepared, aircraft barely became airborne at the landed in Dryden the wings of the F-28 flight dispatchers were not adequately end of the runway and could not gain were cold-soaked. trained, and ground handling was not sufficient altitude to avoid trees When the aircraft took off, the wings sufficiently prepared. beyond the runway threshold. One were covered with approximately 6 - All these unresolved issues crew member and 44 passengers sur- 13 mm of wet snow. Several passen- increased the workload of the flight vived the impact and subsequent fire gers including two off-duty pilots crew and made decision-making more but 24 people perished. observed how the wet snow on the complex. The crew of Flight 1363 cold-soaked wings turned into a thin, lacked company regulations in numer- Running Out of Options rough coat of ice. A passenger alerted ous areas such as hot-refueling with The captain of Flight 1363 was run- a cabin crew member before the take- passengers on-board, the need for a ning an hour and ten minutes behind off roll about his observation but the walk-around before every flight and schedule when he initiated the fatal flight attendant did not bring the pas- clear procedures for performance cal- take-off roll in Dryden. He was aware senger’s concerns to the attention of culation on contaminated runways). that many of his passengers had con- the commander. necting flights. On the ground prior to The swept wings of the F-28 do not tol- A Test of Character departure the situation had been diffi- erate any contamination. Previous F-28 On that fatal day in Dryden, opera- cult. The aircraft had an inoperative accidents and incidents had been attrib- tions control basically left the crew APU. During the turn-around it started uted to contamination of the wings. alone so that they were confronted to snow heavily. Dryden was not Both Air Ontario pilots were made with a situation they could not resolve. equipped with a ground cart to start aware of this point during their F-28 Had operations control and the crew the engines. Therefore one engine had type training. At the time of the accident taken a different decision earlier on in to be left running during the turn- the pilot-in-command had 82 hours on the day, they could have avoided run- around. To minimize ground time the type (total time: 24,100 hours), and the ning out of options during the turn- crew left the passengers on board dur- first officer had 66 hours on type (total around in Dryden. Planning ahead and ing the hot re-fuelling. time: 10,000 hours). Despite their con- understanding the implications of BART: FEBRUARY - APRIL - 2012 - 73 SAFETY SENSE RULES AND REGULATIONS Justice Virgil P. Moshansky, adopted a reminds us of the importance of the new way of taking into account the individual’s decision making in avoid- wider managerial and systemic issues ing accidents and incidents. This is causing aircraft accidents. To simply particularly true in a Business Aviation attribute the accident to pilot error environment, where flight crews are would not have correctly reflected the often entrusted with a wide range of complex web of contributory and decision powers by small and very causal factors. Justice Moshansky ‘lean’ organizations. skillfully included “management infor- The Dryden crew was certainly quali- mation” into the accident report, as ty minded, quality perceived in the discussed in ICAO in the early 90s sense of customer satisfaction. When and as introduced in edition 8 of faced with the implicit dilemma of Annex 13 (ch. 1.17) in 1994. either cancelling the flight due to The findings of the Commission weather and inadequate ground sup- report triggered many significant port or trying to make the flight, the decisions further on in time is a key improvements in flight safety, one of commander decided for the go-option. skill for any pilot. The crew of flight which was the development of winter He wanted to satisfy his passengers’ 1363 ended up in a situation where the operations procedures, including de- expectations and try to ensure that only alternative to their chosen course icing on the ground. As a direct result they made the connecting flights. By of action was to cancel the flight. This the use of hold-over-tables became pushing service delivery to the limit, was not a viable option for them. standard practice during the 1990s. he sadly made the wrong decision. Their sense of duty and service Today’s winter operations are much towards their passengers was stronger safer thanks to the lessons learned ✈ than the perceived danger of taking off from the Dryden accident. with snow-covered wings from a conta- Michael R. Grüninger is Managing minated runway. They wanted to Making the Right Choices – Director and Capt. Carl C. Norgren is accommodate their passengers’ wish A Return to Individual Responsibility Head of Business Development at Great to make their connecting flights ahead Over the past few years James Circle Services (GCS) Safety Solutions. of a long public holiday weekend. Reason, one of the leading researchers GCS assists in the whole range of plan- Customer satisfaction as measured in in the field of aviation psychology and ning and management issues, offering punctuality and reliability was in fact inventor of the “Swiss Cheese Model”, customized solutions to strengthen the put above operational and safety con- has started questioning the organiza- position of a business in the aviation siderations. tional safety approach. He asks: “But market. Its services include training has the process gone too far towards and auditing (IS-BAO, IOSA), consul- A Water-Shed Case collective responsibility and away from tancy (IS-BAO, IOSA), manual devel- in Accident Investigation individual responsibility?”[1] opment and process engineering. GCS The Dryden accident became the James Reason’s question does not can be reached at www.gcs-safety.com first case in which accident investiga- imply that organizational factors are and +41-41 460 46 60. The column tors, under the leadership of a any less important or influential when Safety Sense appears regularly in BART Commission of Inquiry chaired by it comes to accidents. He simply International. 74 - BART: FEBRUARY - APRIL - 2012.

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