Air Ontario Flight 1363 - A Cabin Crew Perspective

Air Ontario flight 1363 was a Fokker F28-1000 twin jet flight on 10 March 1989. The captain was George Morwood and the first officer was Keith Mills. In the cabin were the in-flight coordinator, Katherine Say, and flight attendant Sonia Hartwick. Katherine was an experienced crew member and had been flying for ten years. She had just been promoted a month before the flight. Katherine was known as an excellent crew member with a very professional approach to her duties. Sonia had been flying for two and a half years and was professional and competent. On The Day The crew arrived at the Air Canada counter at Winnipeg International Airport at 06:40 to prepare for the flight. The plan was to fly from Winnipeg to Thunder Bay and return with stops via Dryden, both ways. After that, they were to fly again from Winnipeg to Thunder Bay, without the stop at Dryden. They departed at 07:25 for the six flights ahead. The passenger load was heavy from Thunder Bay, as it was spring break and many families were going on vacation. Extra passengers were added from another flight that had been cancelled. The aircraft was then found to be overweight, so there was no other option but to delay the flight and defuel the aircraft. It would have to refuel again at Dryden. Issues The flight release form was given to the captain, but he found that it was full of mistakes, and he did not question it. The auxiliary power unit on the aircraft had not been working for the previous five days. The captain was informed by the company that one engine should be left running at Dryden. If they switched the engine off, they had no means to restart it. They refueled at Dryden as planned but were now running late. The company policy was that de-icing could not take place with the engines running. Snow was starting to settle on the wings of the aircraft. Problems In The Cabin The flight attendants had noticed many discrepancies in the cabin that week. C-FONF was missing oxygen equipment, the main cabin door was difficult to close and would not lock properly. The emergency floor lighting was dim, and the emergency exit lights were not working. The issues had all been reported in the aircraft journey log. The flight crew were also aware, and the captain expressed his frustration that the repairs and replacements hadn't been done. The Flight There were 65 passengers onboard the aircraft, some from the previous flight from Thunder Bay and new passengers who boarded in Dryden. The safety demonstration was performed, 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. The aircraft waited on the runway for another aircraft to land before they could take off. 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, and if snow was a problem, surely they'd have noticed? "I'm staring at the wing. Because, at this time, as we rolled down the runway, the snow was now turning to ice on this wing, it was freezing to the wing," said Sonia. What Happened Next The aircraft commenced take-off. It attempted to rotate, did not succeed, and then tried to rotate a second time. Sonia described the aircraft bouncing, dropping and bouncing again. The aircraft jerked to the left, and she saw the left wing moving downwards. A passenger said 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 when the aircraft left the runway, but it was just 15 feet above the ground. The Aftermath Sonia and Katherine shouted at the passengers to brace, "Grab your ankles, get your heads down." The aircraft struck the trees and continued, leaving a trail of wreckage behind it. There were sounds of the aircraft hitting the trees, 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 then silence, followed by a fireball, and smoke and fire engulfed the aircraft. Baggage had fallen out of the overhead lockers. There was snow, mud, and bits of trees in the cabin. They could smell aircraft fuel and smoke. Surviving passengers were either in shock or unconscious. Surviving The Accident Sonia saw fire in the cabin and shouted to the passengers to evacuate. They evacuated via a gaping hole in the rear of the cabin and the emergency window exit on the right side of the cabin. The passenger seated next to Sonia opened the window exit, and she followed him out. She shouted to passengers to stay away from the aircraft and kept them together in a group. Some had burns and were injured. They were not dressed for the freezing conditions, in shirt sleeves and stockinged 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. 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 found carrying an infant in her arms. It had been twenty minutes since the accident. Sonia was in shock but continued to keep the survivors together and gave them first aid. Forty-four passengers and Sonia had survived, two died later in the hospital. The Accident Report The CVR and FDR were 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 and ice on the wings. Numerous things had happened that day that contributed to the accident. The captain had made some questionable decisions and was not backed up by the resources he needed. The accident caused many changes within the aviation industry, including changing deicing procedures, fitting shoulder harnesses to flight attendant jump seats, and the introduction of fire-retardant materials in the aircraft cabin. Crew resource management was highlighted as an issue in communication between the flight attendants and the flight crew. "Well, we have - the pilots and the flight attendants have respect amongst one another as friends, but when it comes to working as a crew, we don't work as a crew. We work as two crews. You have a front-end crew and a back-end crew, and we are looked upon as serving coffee and lunch and things like that," said 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. Sonia had wished to return to flying, but would not return until changes were made. She felt that she appeared stupid and ashamed when relating safety concerns to pilots. Sonia said the Air Ontario management was not supportive of flight attendants voicing their concerns. This created a culture of silence. Thankfully, Crew Resource Management (CRM) is a very important part of aviation training and we continue to learn from previous accidents and what we can do to prevent them.