Many occurrences led to the tragedy
Air Ontario Flight 1363 took place on a Fokker F28-1000 twin jet on 10 March 1989. The captain was George Morwood and the first officer was Keith Mills. Working in the cabin were inflight co-ordinator Katherine Say and flight attendant Sonia Hartwick. Katherine had been flying for ten years and had been promoted just a month before the flight. She was known to be an excellent crew member with a professional approach to her duties. Sonia had been flying for two and a half years and was competent and professional.
On the day
The crew arrived at the Air Canada counter at Winnipeg International Airport at 06.40 to prepare for the day’s flying. The flight was from Winnipeg to Thunder Bay and returning with stops via Dryden both ways. Afterward, the plan was to fly again from Winnipeg to Thunder Bay, without the stop at Dryden. It was a total of 6 legs and they departed at 07.25. There was a heavy passenger load from Thunder Bay as it was spring school break and families were going on vacation. The aircraft had refueled, but with extra passengers from a canceled flight, the aircraft was overweight. There was no choice but to delay the flight whilst the aircraft was defueled. They needed to refuel again at the second stop at Dryden.
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Problems
The flight release form given to the captain was full of mistakes, which he did not question. The auxiliary power unit on the aircraft was not working for the previous five days. The captain was informed by the company that one engine should be left running at Dryden. If the engine was switched off they had no means to restart it. They refueled on the second stop at Dryden as planned. The previous flights had them running an hour late. Company policy said that no deicing could take place with engines running. Snow was starting to settle on the aircraft wings.
Issues in cabin
The flight attendants had noticed many deficiencies in the cabin equipment that week. G-FONF was missing oxygen equipment, the main cabin door was difficult to close and would not lock properly. The emergency floor lighting was too dim and the emergency exit lights were not working. They had been written in the aircraft journey log. The flight crew were aware and the captain expressed his frustration that the repairs hadn’t been done.
The flight
There were 65 passengers onboard, some from the previous flight from Thunder Bay and some who boarded in Dryden. The safety demonstration had taken place and the passengers paid some attention. Sonia had noticed the snow on the wing, she was seated in seat 8D in the cabin. Katherine was seated at the front of the aircraft. They waited on the runway for another aircraft to land before take-off could commence. Sonia didn’t say anything about the snow as she felt that the pilots did not welcome operational information from crew members. She trusted the pilots. If ice was a problem surely they’d have noticed.
Photo: Bureau of Aircraft Accidents Archives
What happened next
The aircraft commenced take-off. It attempted to rotate, not succeeding and then tried to rotate a second time. Sonia described the aircraft bouncing, dropping, continuing, and bouncing again. The aircraft jerked to the left and she saw the left wing going down. A passenger noticed that the aircraft ‘didn’t want to leave the runway’ and was different from the previous flight. There was a change in pitch of the engines and the aircraft left the runway, just 15 feet off of the ground.
Aftermath
Sonia and Katherine shouted at the passengers to brace, ‘grab your ankles, get your heads down’. The aircraft struck trees and continued forward leaving a trail of wreckage behind it. There were battering sounds, the crunching of metal and passenger screams and yells. It finally came to a stop, breaking into three pieces in a ‘U’ shape. There was silence and then a fireball and smoke. Fire engulfed the aircraft. Baggage had fallen from the overhead lockers. There was snow, mud, parts of trees in the cabin. There was a smell of aircraft fuel and smoke. Surviving passengers were either in shock or unconscious.
Survival
There was fire in the cabin. Sonia shouted to the passengers to evacute. They evacuated via a gaping hole in the rear of the cabin or the emergency window exit on the right side of the aircraft. The passenger next to Sonia, had opened the window exit and she followed him out. She shouted to passengers to stay away from the aircraft and kept them together in the woods. Some had burns and were injured. They were not dressed for the freezing conditions, in shirt sleeves and stocking feet. Sonia had lost one shoe on the aircraft and another in the snow. She borrowed a passenger’s shoes so that she could continue her duties to the survivors.
Waiting for rescue
Two passengers were trapped in the wreckage and later pulled out. Twenty-two people died at the site including Katherine and the flight crew. A firefighter gave Sonia his coat, she was carrying an infant in her arms. It was twenty minutes since the accident. Sonia was in shock but continued to keep the survivors together, encouraged them and gave first aid. Forty-four passengers and Sonia had survived. Two died later in the hospital.
Report
The CVR (cockpit voice recorder) and FDR (flight data recorder) were completely destroyed in the fire, so witness accounts were pieced together to find out what had happened. The aircraft had not been able to gain enough altitude to clear the trees at the end of the runway, due to snow or ice on the wings. Numerous occurrences during the day had contributed to the accident. The captain had made questionable decisions and was not backed up by the resources he needed. The accident caused many changes within the aviation industry, including deicing procedures, fitting shoulder harnesses to jump seats and the introduction of fire retardant materials in aircraft. Changes in regulations were made. Crew resource management was highlighted as an issue.
Sonia
Sonia later found she had a fractured skull and was placed on medical leave. She felt guilty that she’d not mentioned the snow on the wings. She pointed out the deficiencies in training and the working relationships between flights and pilots. She wished to return to flying but would not return until changes were made. She felt that she appeared stupid when relating safety concerns to pilots. Sonia said the Air Ontario management were not supportive of flight attendants voicing their concerns.
Source: simpleflying.com
