Where Birds Don't Fly

On March 10, 1988, an aircraft crashed shortly after takeoff during winter condition operations. Air Ontario Flight 1363 was a scheduled Air Ontario passenger flight which crashed near Dryden, Ontario, on 10 March 1989 shortly after takeoff from Dryden Regional Airport. The aircraft was a Fokker F28-1000 Fellowship twin jet. It crashed after only 49 seconds because it was not able to attain sufficient altitude to clear the trees beyond the end of the runway, due to ice and snow on the wings. At that time there were no regulated safety management system (SMS) in place and the accident generated several safety improvements and operational changes to aviation. A question to ask is if the same accident could happen today with an implemented and operational SMS. SMS is not a system that is dependent on a specific person in charge but is reliant on processes. If processes are incomplete, then the same type of accident could happen again today with an SMS. Prior to SMS became the regulatory r...

If the safety management system (SMS) of today could have prevented the March 27, 1977, worst aviation accident in history when two B-747 at the Los Rodeos Airport on Santa Cruz de Tenerife is a question without answers. There are no answers since SMS is forward-looking and accidents cannot be predicted until the last few seconds when it is evitable that an accident will occur. At the time of the accident, it was assumed that aviation was operating with safe and fail-free systems, except for pilot errors as the bad apples in the box. Pilot error had become industry acceptable root cause to any accidents. It is unknown when pilot error became the popular root cause solutions, but accident reports since the late 60’s and early 70’s support this as a solution. However, after the June 30, 1956, Grand Canyon disaster, the probable cause of the mid-air collision was not allocated to pilot error, but that the pilots did not see each other in time to avoid the collision due to other multiple f...