Thomas Ovans uses the internet to solve mysteries round an air crash fifty years ago
… and also uncovers some more recent concerns
On the morning of September 2nd, 1958 I had arranged to go on a cycle ride with a few school friends – probably our last excursion of the summer holidays. As we gathered at around 9 am, one of our group arrived with the news that there had been a plane crash in Southall, only a few miles away. He may even have claimed to have heard the sound of the aircraft coming down.
Being schoolboys, I suspect we all felt a shiver of excitement that something dramatic and shocking had come so close to our ordered suburban lives. I don’t recall being tempted, however, to go and see the scene of the accident. Instead we set off, as planned, for a ride in the Surrey countryside; and I suspect that, by lunchtime, we had forgotten about the Southall crash. It is perhaps significant, though, that during the afternoon we had the idea of staging and photographing a mock accident involving a heap of bicycles and several of our arms and legs protruding from the hedge and ditch.
In the days that followed I was oddly incurious about details of the crash. I think I assumed there had been a sudden loss of control after take-off from nearby Heathrow; and hence I pictured the aircraft coming down from a fairly steep angle with very little warning. It was only recently – over fifty years after the incident – that I thought of using the internet to try and find out more about what happened. It was surprisingly easy to get some basic information ,  which showed that my assumptions had been wrong. But it has proved much more difficult to discover an adequate explanation for that morning’s events. What I did uncover, however, were some commercial and political attitudes and behaviours which do not seem to have changed much since 1958.
Some essential facts of the story can be gleaned from , , . At 05.54 GMT on September 2nd a twin-engine Vickers Viking aircraft, call-sign Juliet-Echo, took off from Heathrow airport with a crew of three, with freight bound for Tel Aviv. It was operated by Independent Air Travel. After fifteen minutes (when it was at about 7000 feet over the Horsham area) the captain reported engine trouble and asked for air traffic clearance to land at Blackbushe airport in Surrey . At this stage both engines were still running but the starboard one was throttled back. A few minutes later, however, the pilot said the starboard engine was stopped and “feathered” (i.e. its propeller blades had been set to a minimum-drag position).
At about the time of this second message Juliet-Echo began steadily losing height. Even as the pilot was striving to coax the aircraft as far as Blackbushe, it was slowly falling out of the sky (at about 200 feet a minute); and with an awful and tragic inevitability it ploughed into houses in Kelvin Gardens, Southall at about 06.30 GMT. All three crew members died in the crash together with four people on the ground.
British Pathé newsreel footage  shows the extent of the destruction. The aircraft seems to have hit the ground at quite a shallow angle and the commentator makes the poignant observation that in the last seconds the captain was seen leaning out of his cockpit window shouting and waving in a desperate and probably futile attempt to warn people in the street.
Two questions immediately presented themselves to the accident investigators. Firstly, why was the aircraft unable to maintain height? The Viking was designed to fly safely with one motor stopped; and indeed Juliet-Echo had very recently been shown to be capable of climbing at better than 600 feet/minute on a single engine. Secondly, why was the aircraft anywhere near Southall? To reach Blackbushe from Horsham the aircraft should have flown north-west; but Southall is to the north of Horsham and some 20 miles east of Blackbushe.
The public inquiry into the accident concluded that part of the answer to the first question lay in the fact that the aircraft had been 400 kg above its maximum take-off weight when it left Heathrow. (The flight-test showing that the aircraft could maintain height with one engine stopped had been performed under light load conditions.) This 400 kg overloading was due to extra fuel having been taken on – perhaps to enable one of the refuelling stops to be avoided.
The inquiry also felt that an explanation of Juliet-Echo’s inadequate single-engine performance might lie in some strange events that took place before the flight left Heathrow. On September 1st, the day before the accident, the aircraft made a short positioning flight from Blackbushe (its maintenance base) to Heathrow (to take on its cargo). On arrival at Heathrow, a loss of oil from the starboard engine was noted and members of the flight crew decided to do a partial strip-down and rebuild of the propeller unit in order to try to find and fix the leak. It was of course both unusual and entirely contrary to air transport regulations for them to attempt such a task which was a job for a licensed engineer. It was even more unusual that it was done at night and in the open air.
Examination of the wreckage yielded no evidence that the propeller unit had been incorrectly re-assembled; but nevertheless the public inquiry concluded, on the basis of this incident and also a number of others, that there was a generally cavalier attitude towards proper maintenance procedures within Independent Air Travel. This observation cast doubt upon the overall serviceability of the aircraft and might account for its poor single-engine performance. The inquiry report includes the damning comment that “the policy of this company was to keep its aircraft flying at all costs and without any real regard for the requirements of maintenance.” 
As to why Juliet-Echo was heading in the wrong direction, the inquiry could only conjecture that the pilot had been homing in on the wrong radio beacon. The last few messages from the aircraft showed that the crew believed they were within five miles of Blackbushe when in fact they were more than 20 miles away. Their outward journey had overflown beacons at Epsom and Dunsfold; and after turning back the pilot was told to return to Dunsfold and then tune his direction finder to the Blackbushe frequency. However the subsequent flight-path suggested that one of the pilots might have mistakenly re-tuned to the Epsom signal that had guided them on their outward route.
This use of the wrong beacon probably meant that – until the last few minutes – the crew were not aware of being in much danger. The persistent loss of height would have been worrying, but if they believed they were getting nearer to Blackbushe they must have expected they could stay in the air long enough to make a safe landing. It must have been a sudden and terrible shock to realise that the landscape below them did not match the familiar approach to the Blackbushe runway. This would explain why they did not broadcast a mayday distress call until just before the crash.
To make such a navigational mistake (and to persist in it, in spite of counter-evidence such as the position of the sun) would of course constitute “pilot error”. And “pilot error” could also have accounted for the aircraft failing to stay in the air – if, for instance, its airspeed had been allowed to get too low. But, when commenting on the crew’s responsibility, the inquiry had to take into account the possibility of severe fatigue. There was evidence that during August 30th and 31st the aircraft’s captain was effectively on duty for thirty-one and a half hours. (The maximum permitted time without rest was sixteen hours; but long periods of duty were not technically illegal owing to a loophole in regulations which allowed pilots to fly during “rest” time provided they were not carrying passengers or cargo.) It also emerged that on September 1st, the day before the crash, he was again on duty from 1325 hr until at least 2000 hr and that he then returned to the airport at about 0400 hr on September 2nd in order to prepare for the fatal flight. “In short,” the inquiry report states, “this crew had not had the rest desirable, and to which they were entitled . . . before taking off in an overloaded aircraft whose condition was suspect.” 
The inquiry report makes further criticisms of the way Independent Air Travel carried out routine proficiency checks on their pilots. The most recent such check on Juliet-Echo’s captain was found to have been “perfunctory”. In particular “a true stoppage of an engine and single-engined landing both by day and by night were not carried out”. Hence it provided “no sufficient check on the captain’s ability to fly and land the aircraft with one engine inoperative.”  In view of these less-than-rigorous crew-training procedures – on top of suspected lax maintenance and long working schedules – the inquiry decided that the captain “was put in a situation which no pilot should be required to face and it is dangerous to criticize his handling of it.” 
The inquiry also commented that “The attitude of the company was remarkable. Those directors who gave evidence put the whole blame for this accident on the captain. It was said that the loading responsibility was his, and his the responsibility for taking-off in the aircraft…. It is not difficult for employers who are not unduly concerned to observe the regulations, to drive their employees … to disregard the regulations designed to ensure safety in the air.” 
The impression given by the inquiry report is that Independent Air Travel was operating as a ruthlessly cost-cutting business. Its managing director – himself a pilot – came across as a rather swashbuckling figure when interviewed. As the name of his company suggests, he seemed to enjoy competing aggressively with the larger nationalised airlines. One suspects that certain aspects of his business model would be looked at favourably by some of today’s entrepreneurs who like to boast about leanness and efficiency and the importance of risk-taking. Of course I do not accuse any present-day organisations of setting out to break the law. But, for any business manager who takes pride in cost-saving measures, the words of the Southall inquiry are still relevant: “it is not difficult for employers … to drive their employees … to disregard the regulations”
In view of the inquiry’s findings it might have been expected that Independent Air Travel would have faced prosecution – perhaps even for manslaughter, but at least for failures in operating procedures. The fact that this did not happen led to some acrimonious exchanges in parliament over the following two or three years. And if a narrative about unintended consequences of cost-cutting is one which sounds both familiar and plausible in 2011 then so also is a narrative involving accusations of ministerial incompetence or even complicity in questionable business dealings.
In a civil aviation debate on 20 July 1959 Hansard  reports suggestions by opposition MPS that the Ministry of Transport and Civil Aviation had been too light-touch in regulating the airline industry – not policing maintenance requirements tightly enough and not closing the legal loophole which allowed pilots to continue flying during “rest” periods. These allegations were of course refuted. In particular a long statement was made by the MP in whose constituency Independent Air Travel’s headquarters were located. This statement sought to cast doubt on the Southall inquiry’s findings.
The constituency MP argued, for instance, that Juliet-Echo’s overloading was not a significant factor in the accident (likening it to doing 32 mph in a 30 mph area). This seems an arguable point; but he then went further and questioned the evidence for crew fatigue, stating that the captain had been heard to say he felt “very fit” on the day before the crash. The MP also claimed it had been entirely the captain’s decision to leave Heathrow at around 6 am on September 2nd – the company’s schedule for the round trip to Tel Aviv meant that he could have left later in the day if he had indeed felt tired. (It is however hard to square this claim with the fact that the crew had felt it necessary to do emergency repairs the night before instead of waiting for a qualified mechanic.) Finally he said he had listened to tape recordings of the crew’s last messages in which their voices showed “no trace of tiredness”. (In a tense situation, however, adrenaline would surely have temporarily compensated for fatigue.)
(It should be said that the MP had very properly preceded his statement by declaring his interest in the matter – namely that he had for many years been a friend of the managing director of Independent Air Travel and moreover that he had recently become a director of Falcon Airways – a new company founded by the very same managing director.)
Hansard also reports  that on 21 December 1961 – over three years after the accident – the Attorney General was asked why there had been no prosecution of Independent Air Travel. Suspicions were voiced that delaying tactics might have been employed within the Department of Public Prosecutions to prevent such a prosecution taking place. Such suspicions were based, in part, on the fact that a former employee of the DPP had subsequently gone to work for Falcon Airways (see above). Naturally the Attorney-General strongly resisted any implication of wrongdoing; but he also went further towards undermining the Southall inquiry by drawing attention to a conflict of evidence about the aircraft’s overloading which would have made it hard to achieve the standard of proof needed for a conviction even if a prosecution had been brought.
So, three years after the accident, we find a swirl of accusation and counter-accusation around events which had – or had not – taken place. By 1961 Independent Air Travel had ceased to exist (after briefly rebranding itself as Blue Air). Its former managing director had resigned in 1959 – saying his departure “has nothing whatsoever to do with the accident”  – in order to start up Falcon Airways – which itself ceased operating in 1961 amid concerns about its safety record. 
Many of the questions raised in 1958 still remain unresolved. Were the crew (and the occupants of 6 Kelvin Gardens) victims of an unscrupulous company which insisted on over-long hours being flown in unsafe aircraft? Were the government complicit in this by weak regulation and weak enforcement? Was the lack of a subsequent prosecution partly a cover-up of government mistakes with a touch of conspiracy or corruption thrown in? We may be inclined to believe ‘yes’ could be the answer to any or all of these questions. And yet it may be the case that the crew of Juliet-Echo simply made some fatal mistakes.
The possibility of pilot error arises again because of a puzzling claim in the Hansard report . The MP defending Independent Air Travel mentions something which, he says, was omitted from the inquiry report – namely that no fault was found in Juliet-Echo’s starboard engine. But if this is true, why did the crew report an engine problem and abort the flight? Did this accident prefigure the Kegworth disaster of January 1989 which was caused by pilots shutting down a correctly operating power plant by mistake?
Pre-flight doubts about the starboard engine (which had prompted last-minute repairs the night before) centred on the propeller unit rather than the power plant itself. Problems of “surging” had previously been reported  in the constant speed unit (csu) which automatically adjusts the propeller blades during flight. In one of his last messages, Juliet-Echo’s pilot stated “I have one engine feathered and don’t seem to be able to unfeather it at the moment.”  As mentioned earlier, a “feathered” propeller has its blades set to reduce air resistance when an engine is stopped. But the pilot’s remark suggests he wants to unfeather the propeller – perhaps in order to start the engine again. Could the starboard csu have had an intermittent fault which allowed the propeller blades to become feathered while the engine was running? This might have caused erratic or asymmetric application of thrust and compelled the pilot to shut down a perfectly good engine. But this is guesswork and, among the many possible contributing factors to the accident, even the root mechanical cause for Juliet-Echo turning back remains unclear.
The Hansard report  also describes how features of the air traffic control system had thwarted one last chance of preventing the disaster. Because of the navigation error, Juliet-Echo was actually quite close to Heathrow when it crashed and it might have been guided to a safe landing there if communication with Heathrow control had been possible. But because Juliet-Echo’s crew were in radio contact with Blackbushe, the Heathrow control tower could not speak to them. Paradoxically, Heathrow’s radar could follow the Juliet-Echo’s progress while the smaller airport at Blackbushe did not have the radar to detect that the aircraft was off -course. Hansard aptly sums up this tragic conflict of partial information: “London could see the Viking but could not speak to it. Blackbushe could speak to the Viking but could not see it. London knew its position but not its height. Blackbushe knew its height but not its position. If either airport had known both facts together the aircraft could have been taken over by London Airport and safely landed.” Among these mutual contradictions the last hope vanished for the crew of Juliet-Echo to escape the consequences of a sequence of tragic errors (however they occurred and whoever was to blame for them them).
It has been interesting but distressing to discover that muddled and unsatisfactory conclusions could result from parliamentary debates and public inquiries back in 1958 in just the same way as they have done in more recent times. Contemporary discontent with politicians (and their interactions with business and the media) may tempt us to believe there was a slightly-more-golden age fifty years ago when straight-talking politicians and clear-thinking commentators joined forces in the interests of perfect transparency. Evidently this was not the case.
As I said earlier, I have always felt ‘close’ to the Southall disaster even though I knew little about it. My quite unjustifiable sense of somehow being “involved” with its mysteries has continued throughout my belated gathering of the available and contradictory facts. In fact I experienced a small extra frisson when I discovered for the first time that Juliet-Echo had been trying to reach Blackbushe airport because, coincidentally, we went quite near there on our cycle ride later that fateful day. However my internet search produced one last “hit” to remind me of the insignificance of my activities on September 2, 1958 compared with those of another fourteen year old. A short newsreel clip of 1959  records the presentation of a Carnegie medal to a Southall schoolboy for saving his five-year-old nephew from the fire which followed the crash of Juliet-Echo on Kelvin Gardens.
 Vickers 621 Viking 1 G-AIJE London Airport (LHR) . Aviation Safety Network. 15 April 2007.
 “Air Commerce: The Southall Accident: Report of the Public Inquiry“. Flight, 21 August 1959, p. 58.
Until Thomas Ovans began writing for London Grip, his prose mostly appeared in technical or academic publications.