Disasters That Sparked The Most INTENSE Investigations | XMAS SPECIAL | Mayday: Air Disaster

Mayday: Air Disaster
25 Dec 2022139:32
EducationalLearning
32 Likes 10 Comments

TLDRThe video script recounts a series of dramatic aviation incidents, starting with the tragic crash of Air Ontario Flight 1363, which was caused by a combination of factors including pilot error, a broken APU, and a lack of de-icing. The narrative then shifts to the harrowing Operation Babylift mission during the Vietnam War, where a C5A Galaxy aircraft, overloaded with orphans and desperate civilians, suffered a catastrophic decompression and crash. Lastly, the story covers the mysterious crash of Chalk's Ocean Airways Flight 101, which investigators ultimately attribute to structural failure stemming from a fatigue crack in the wing, exacerbated by poor maintenance practices and financial struggles within the airline. These incidents highlight the critical importance of safety protocols, regular maintenance, and the role of corporate culture in preventing such tragedies.

Takeaways
  • ✈️ The Air Ontario Flight 1363 crashed due to wing contamination from ice and snow, which disrupted airflow and caused a loss of lift.
  • ⏱️ The crash occurred after a series of delays and miscalculations regarding the plane's weight and balance due to additional passengers and fuel adjustments.
  • 🚨 Captain Morewood did not request de-icing before takeoff, possibly due to the lack of proper equipment at Dryden Airport and the risk of engine ingestion of de-icing fluid.
  • 🔍 The investigation revealed that the plane was not overweight at takeoff, but the lack of a pre-takeoff weight and balance form raised questions about the accuracy of this conclusion.
  • 🛫 The decision to take off without de-icing was influenced by the pressure to maintain the flight schedule and the potential costs and inconvenience of de-icing with an engine running.
  • 👤 Justice Virgil Moshansky's inquiry highlighted the need for better pilot training, improved de-icing protocols, and the use of a more effective type 2 de-icing fluid.
  • 📉 The investigation into Flight 1363 led to significant changes in aviation safety practices, including the implementation of runway de-icing pads and the use of Type 4 de-icing fluid with a longer lasting effect.
  • 🛑 The crash of U.S. Air Flight 405, another Fokker F-28, underscored the importance of Moshansky's recommendations and the need for better adherence to de-icing procedures during winter conditions.
  • 💡 The use of runway and icing pads for final de-icing before takeoff was a direct result of the Dryden commission inquiry, enhancing aviation safety measures.
  • 🛑 The FAA's oversight of Chalk's Ocean Airways was criticized for not identifying and addressing the airline's financial and maintenance issues, which contributed to the crash of Flight 101.
  • 🔧 Poor maintenance practices and a lack of proper inspections on the aging Grumman Mallard aircraft led to structural failure, resulting in the crash of Chalk's Flight 101.
Q & A
  • What was the date and time when Air Ontario Flight 1363 stopped in Dryden, Ontario?

    -Air Ontario Flight 1363 stopped in Dryden, Ontario on March the 10th, 1989, at 11:39 a.m.

  • Why did the passengers of Air Ontario Flight 1363 remain on board during the refueling process?

    -The passengers stayed on board while the plane was refueled, likely due to the cold weather conditions and the remote location of the airport.

  • What was the weather condition like when Air Ontario Flight 1363 was preparing to depart Dryden?

    -The weather was deteriorating with heavy snowfall, decreasing visibility, and temperatures around freezing.

  • What was the cause of the delay for Flight 1363 before its departure from Dryden?

    -The delay was caused by an urgent request for landing from an approaching Cessna 150, which held up the takeoff of Flight 1363.

  • What was the sequence of events that led to the crash of Air Ontario Flight 1363?

    -The sequence included the plane struggling to get airborne, shaking, clearing the trees, a power burst that seemed to stabilize the plane, followed by a loss of control, and a crash landing in the bush 950 meters west of Runway 29.

  • How many passengers and crew survived the crash of Air Ontario Flight 1363?

    -45 people survived the accident, but 24 people, including Captain Morewood and First Officer Mills, did not.

  • What was the role of the Royal Canadian Mounted Police Officer, Don Crawshaw, in the events of Flight 1363?

    -Don Crawshaw and his partner were escorting a prisoner to Winnipeg, and after the crash, Crawshaw helped to release the prisoner from his handcuffs and guided passengers to safety.

  • What was the primary reason for the crash of Flight 405?

    -The primary reason for the crash of Flight 405 was the accumulation of ice on the wings, which caused a loss of lift during takeoff.

  • What was the name of the investigation that led to significant changes in de-icing procedures and the development of new de-icing fluids?

    -The investigation was known as the Dryden commission inquiry.

  • What was the name of the operation that aimed to transport Vietnamese orphans to safety during the fall of Saigon?

    -The operation was called Operation Babylift.

  • What was the cause of the crash of the C5A Galaxy aircraft during Operation Babylift's first flight?

    -The cause of the crash was the failure of the cargo door, leading to rapid decompression and loss of control over the aircraft.

  • What was the final conclusion of the investigation into the C5A Galaxy crash during Operation Babylift?

    -The investigation concluded that the crash was caused by three improperly closed locks on the cargo door, which were forced open by the building air pressure during the flight.

Outlines
00:00
🛬 Emergency and Delay in Ontario: Air Ontario Flight 1363

On March 10, 1989, at Dryden, Ontario's airport, amidst heavy snowfall, Air Ontario Flight 1363 experienced significant delays. The plane stopped for refueling as passengers, many of whom had vacation plans for the March break, stayed onboard. The pilots, Captain George Morwood and First Officer Keith Mills, checked weather conditions and decided to proceed despite the snow, believing they were still within safe takeoff limits. The community's small, remote location and the harsh winter conditions underscored the urgency and risks associated with their decision to continue.

05:01
🚀 Critical Moments Before Takeoff: Tension and Preparations

Tensions rose as the flight was already delayed by an hour, and another incoming aircraft's landing request further delayed the takeoff of Flight 1363. During this time, passengers were informed about the situation and instructed to prepare for takeoff. The pilots performed engine checks and other necessary preparations while facing the challenges posed by the continuing heavy snow, which threatened to ground the flight indefinitely.

10:01
🌪️ Disaster Strikes After Takeoff

Flight 1363, after finally taking off, encountered severe difficulties. The aircraft struggled to gain altitude, experiencing sluggish responses similar to a heavily burdened person trying to run uphill. Shortly after liftoff, the plane began to shake violently, and despite the crew's efforts to stabilize the situation, it became evident that a crash was imminent. Passengers were instructed to brace for impact, leading to a chaotic and terrifying scene as the plane eventually crash-landed in the bush, tragically resulting in the deaths of 24 individuals, including the pilots.

15:04
🔍 Investigation and Aftermath: Seeking Answers

Following the crash, an extensive investigation was launched by the Canadian Aviation Safety Board. The team analyzed the flight path, documented evidence at the crash site, and retrieved the black boxes, although they suffered extensive damage making data recovery impossible. Initial findings suggested a combination of factors, including possible weight overloads and inadequate de-icing, contributed to the tragedy. The investigation aimed to establish factual evidence to prevent future occurrences and to understand the sequence of events that led to the fatal crash.

20:07
🛫 Revisiting Maintenance and Safety Protocols

The investigation uncovered maintenance and safety protocol concerns, particularly around the aircraft's history of fuel leaks and the last-minute changes in passenger load that led to the hurried removal of fuel to compensate for weight issues. These issues prompted a deeper inquiry into Air Ontario's operations and maintenance practices, highlighting the need for stringent adherence to safety standards and proper aircraft upkeep to ensure the safety of all passengers.

Mindmap
Keywords
💡Air Ontario Flight 1363
Air Ontario Flight 1363 was a real flight that experienced a tragic crash on March 10, 1989. The flight was en route from Thunder Bay to Winnipeg with a stopover in Dryden, Ontario. The disaster is a central theme of the video, illustrating the consequences of not prioritizing safety protocols. The flight's crash is investigated for causes, including potential icing issues on the aircraft's wings.
💡Dryden, Ontario
Dryden is a small, remote city in Ontario, Canada, with a population of about 6,500. It is depicted as a harsh environment with bitter cold winters, reaching -35 degrees Celsius. In the video, Dryden is the location where Air Ontario Flight 1363 stopped to refuel and where the subsequent crash investigation took place, highlighting its significance in the narrative.
💡De-icing
De-icing is the process of removing or preventing the build-up of ice on the wings and other parts of an aircraft, which is crucial for maintaining lift and safe flight, especially in cold climates. The video emphasizes the importance of de-icing as an aviation safety measure, particularly in the context of the Air Ontario Flight 1363 crash investigation.
💡Black Box
Black Boxes are flight recorders placed in aircraft that are designed to record and survive the conditions of a crash for later retrieval and analysis. In the video, the black boxes from Air Ontario Flight 1363 were damaged by extreme heat, making the data unrecoverable. This highlights the critical role black boxes play in crash investigations.
💡Auxiliary Power Unit (APU)
The Auxiliary Power Unit is a device on an aircraft that provides energy for various systems, including starting the main engines. In the video, the APU of the aircraft involved in the crash was not operational, which forced the crew to make a risky decision to refuel with one engine running, a situation that could have contributed to the accident.
💡Cold Soaking
Cold soaking is a phenomenon where the fuel in a plane's wing, which can get extremely cold, causes snow that comes into contact with the wing's metal surface to freeze instantly. The video explains that this process can lead to a barely visible layer of ice that disrupts airflow and destroys the wing's lifting capabilities, contributing to the crash of Air Ontario Flight 1363.
💡Air Crash Investigation
Air crash investigation is the process of determining the cause of an aircraft accident. The video details the meticulous work of investigators, including the examination of weather conditions, aircraft systems, and witness statements, to understand the factors that led to the crash of Air Ontario Flight 1363.
💡Runway Icing Pads
Runway icing pads are facilities located on or near runways used to apply de-icing fluids to aircraft prior to takeoff. The video discusses the implementation of runway icing pads as a result of crash investigations, emphasizing their importance in preventing future accidents due to ice contamination on aircraft.
💡De-icing Fluid Types
Different types of de-icing fluids are used to prevent ice build-up on aircraft. The video mentions Type 1 and Type 2 fluids, with Type 2 being thicker and providing longer-lasting protection against ice. The investigation into the crash of Air Ontario Flight 1363 led to a greater understanding and use of these fluids in the aviation industry.
💡Maintenance and Safety Culture
Maintenance and safety culture refer to the practices, attitudes, and commitment to safety within an organization. The video highlights the importance of a robust safety culture, particularly in the context of Air Ontario's decision to let the plane fly with a broken APU, which is seen as a contributing factor to the crash.
💡Operation Babylift
Operation Babylift was a mission during the Vietnam War to evacuate orphans from South Vietnam to the United States and other countries for adoption. The video describes the tragic crash of one of the Operation Babylift flights, highlighting the desperate and chaotic nature of the mission and the tragic loss of life, including children.
Highlights

Air Ontario Flight 1363 faced numerous delays and challenges, including harsh weather conditions and an hour behind schedule, which raised concerns about connecting flights for passengers.

The aircraft's anti-icing system was operational; however, it only heated the leading edges, potentially missing ice formation on the wings' surfaces.

Investigators discovered that the plane's wings were contaminated with ice, causing a loss of lift and subsequent crash, highlighting the vulnerability of the Fokker F-28 to ice buildup.

The crash of Air Ontario Flight 1363 led to a wide-ranging inquiry, with a focus on the aviation system's contribution to the tragedy.

The investigation revealed that the plane was not overweight at takeoff, contrary to initial suspicions, and the cause of the crash remained a mystery.

The use of hot refueling, while not against regulations, introduced an additional risk due to the potential for fuel spillage.

The Auxiliary Power Unit (APU) was not operational on the day of the crash, eliminating the possibility of an APU-related fire but raising questions about the decision-making process regarding refueling.

Captain George Morwood's decision not to de-ice the plane before takeoff, despite concerns about the weather, was influenced by a combination of factors including airline policy and the lack of de-icing equipment at Dryden Airport.

The crash investigation led to significant changes in aviation safety practices, including the implementation of runway and icing pads, and the use of Type 4 de-icing fluid with a longer lasting effect.

The operation to rescue Vietnamese orphans, known as Operation Babylift, faced chaos and overcrowding, which posed significant logistical challenges.

The C5A Galaxy aircraft used in Operation Babylift experienced a catastrophic failure during takeoff, leading to a rapid decompression and crash, with many fatalities.

The crash of the C5A Galaxy highlighted the importance of proper maintenance and inspection procedures, as the investigation revealed that the cargo door had failed due to a lack of proper rigging.

The investigation into the C5A Galaxy crash led to safety recommendations that improved the design and operation of C5 aircraft, emphasizing the need for thorough checks and maintenance.

Chalk's Ocean Airways, despite its long history and reputation for safety, faced a devastating crash of Flight 101, which was carrying VIP passengers.

The crash of Flight 101 resulted in the loss of all passengers and crew, with the investigation pointing towards a structural failure as the likely cause.

The NTSB investigation into Flight 101's crash revealed that the airline had been plagued by financial difficulties and maintenance issues, which may have contributed to the accident.

The FAA's oversight of Chalk's Ocean Airways was criticized for not detecting the growing maintenance and financial problems that affected the airline's safety.

The crash of Flight 101 led to the end of Chalk's Ocean Airways and prompted the NTSB to recommend expanded oversight of aging aircraft by the FAA.

Transcripts
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