A Christmas Miracle, A Christmas Debacle: The Story of Trans-Canada Air Lines Flight 661
On December 17th, 1954, an incredible moment in Canadian aviation history happened. A Lockheed L-1049 Super Constellation registered as CF-TGG, operating as Trans-Canada Air Lines flight 661, crashed in a farm in what was then-called Chinguacousy Township, now the suburbs of Brampton, Ontario. Despite the aircraft eventually burning up to a crisp, all 23 people on board survived the crash and made it out before it exploded and completely burned up. At the time, it was considered a Christmas miracle, a label it still keeps to this day. However, an investigation found that “the accident was caused by negligence on the part of the captain”, making this a Christmas debacle. After reviewing the investigation, along with the knowledge of future air accident investigations, I believe that this accident was not caused by “negligence by the captain”, but through many factors that the report either minimizes or outright dismisses.
To most people, Trans-Canada Air Lines (TCA) is an airline that has been forgotten. Founded in 1937 by an Act of Parliament, it was a subsidiary of Canadian National (CN) Railways, created out of the fear of airlines from the US gobbling up valuable Canadian flights.² Before then, no large-scale airline existed in Canada, with the closest being James Armstrong Richardson Sr.’s Canadian Airways, based in Winnipeg (whose airport is now named after him), who advocated for his airline to be the main Canadian airline. In fact, Richardson was said to have been “heart-broken” when backroom deals not only took his idea and gave it to CN, but also cut him out of transcontinental routes. Richardson died of a heart attack in 1939, and his airline was one of many that was bought by the Canadian Pacific (CP) Railway Company to form Canadian Pacific Air Lines in 1942, which competed with TCA.³ Eventually, TCA would change its name to “Air Canada” in 1965, which was already the French name since 1954, keeping that name to this day.⁵
After the Second World War, TCA bought Canadair North Stars (British people may know the plane as the Argonaut) in 1947 to expand their route network in Europe and the US.⁵ These North Stars were Douglas DC-4s with newer engines and with a DC-6 nose. However, these were slower and louder than the competition on the same routes, and so, in the early 1950s, after deciding between the Douglas DC-6B and the Lockheed L-1049 Super Constellation, TCA decided to buy new Super Constellations. After a delay due to the Korean War and a strike, TCA got its first Super Constellations in February 1954, and started flying them that May.⁴ The accident plane itself, registered CF-TGG, fleet number 407, was only delivered in July of that year.
The Super Constellation was a longer variant of the Lockheed Constellation, which was a plane with four propeller piston-engines, and had a tail with three rudders. The history of the development of the Constellation is a very interesting one, told beautifully in a video by Mentour Pilot. While the Constellation had its first flight in 1943, the Super Constellation started flying in 1951. It was the fastest plane on the market when it first came out, having a range that could go between the east and west coasts of the US non-stop.
TCA would advertise the luxury of flying on these Super Constellations, sending one of their first ones to Vancouver just for the public to check it out,⁶ and sent another one to Toronto for those people to see as well. According to an article from The Globe and Mail in May 4th, 1954, about 10,000 people were at Malton Airport just to see the plane that could hold up to 75 people on board. The planes became very popular as TCA, initially operating them on their trans-Atlantic route 4 days a week, decided to increase that to a daily operation.⁴ According to Air Canada’s 75th anniversary timeline, “Its pièce de résistance is the most modern galley kitchen in the air: a five-square-metre space, complete with refrigerator, ovens, automatic coffee machines… even a kitchen sink!”
As for the accident flight, Trans-Canada Air Lines flight 661 was a flight from Tampa, Florida to Dorval Airport (now Montreal Trudeau Airport) via Malton Airport (now Toronto Pearson Airport). The flight took off from Tampa at 6:10pm, with an estimated flight time of 3 hours and 15 minutes to Toronto, an extremely quick time with tailwinds along the route providing a huge speed boost. As the Super Constellation was a pressurized aircraft, they flew at 21,000 feet, over most of the weather and the local American air traffic. However, at Toronto, the weather was getting worse, to the point where the cloud ceiling was just 600 feet above sea level, necessitating the use of the Instrument Landing System (ILS), a system that was only installed at the airport six years prior, on “runway 10”.¹
Quick history lesson, Toronto Pearson/Malton Airport had three runways in 1954: runway 5/23, which is its current name, but only after being renamed numerous times; runway 14/32, which was renamed “15/33”, and later renamed to its current name 15L/33R when 15R/33L was built in 1997; and runway 10/28, which no longer exists, and only survives today as taxiways P, G, and AG. These three runways formed a triangle, a common runway pattern in airports around the world at the time to account for any wind direction.
For the flight, the captain for the flight was Norman Ramsay, who was 34 years old and highly experienced. The first officer was Gary Anderson, aged 22, and, given his age, was obviously newer to flying, though started his career at TCA around 1951. As the Super Constellation required a flight engineer, 34-year-old Thomas Gordon Phillips was filling that role. Four flight attendants were on the flight, with Walter Harry Lane as the purser (the lead flight attendant), and the remaining three being John Renaud, Irene Deruchie, and Marlon Doucet, according to an injury list given in the December 18th, 1954 issue of the Toronto Daily Star. One notable passenger on board was Marlene Stewart (now Marlene Stewart Streit), a very successful amateur golfer that would eventually end up in the World Golf Hall of Fame in 2004, being the first ever Canadian to be inducted. In total, 7 crew members and just 16 passengers were on board the flight for the Tampa-Toronto leg.
The take-off, climb, and cruise were normal. When the flight reached Erie, Pennsylvania on the south shores of Lake Erie, the crew began to descend at 9:04pm. Ten minutes later, the Toronto ATC Centre issued its first clearance for the flight: “ATC clears Flight 661 to the ILS outer marker, Runway 10, cross Ash descending the outer marker at four thousand, no delay expected”. Despite “Ash” or “the Ash intersection” being repeatedly referred to in this report, there are no maps nor any description of the location to indicate where “Ash” is, one of many issues I have with this report. From my browsing of Google Maps, I believe this “Ash” refers to a tiny community in what is now Milton, Ontario, north of Oakville and Highway 407.
By the way, this clearance is the only time the flight number appears anywhere in the report, and does not appear anywhere else in any place that talks about this flight! If you search up “Trans-Canada Air Lines flight 661”, you will only get results for Part 1 of my series “The State of Canadian Aviation Investigations” (and this article). This is partly why I wanted to do an article on this: to spread awareness.
By 9:19pm, flight 661 was communicating with the control tower at Malton. At 9:23, the flight was at the Ash intersection. At that time, the tower gave the wind, the runway, and the altimeter setting. Just before they arrived at the Ash intersection, the pilots tuned their two ADF receivers. The captain’s, coloured red, was tuned to the Toronto radio range station, with the first officer’s, coloured green, was tuned to the “outer marker” of runway 10. The red receiver was purely so that in the case of a go-around, the captain could use it to reorient himself. The green receiver was the important one, as it shows where the outer marker is relative to the plane so that they can stay at the appropriate altitudes, and also to guide them into the runway with the aid of the compass. According to the first officer in a Toronto Star article 60 years later, the captain was still getting used to the new system.⁷
Despite the fact that they were cleared to 4000 feet at Ash (at least how I interpreted that radio call), they were actually at 9000 feet, and were going close to 250 knots of indicated airspeed (IAS) (around the modern speed limit for planes under 10,000 feet), picking up that speed from the descent.
From Ash, they went towards the Toronto radio range station, reaching it over 3 minutes after passing Ash, descending to 6000 feet, before making a left turn to the outer marker while trying to decrease the speed so that they can lower the flaps (there’s a speed limit that determines when you can deploy the flaps without the risk of structural damage). The captain also called for the first officer to do the “in range” checklists, which included turning on the “fasten seat belt” and “no smoking” sign. Yes, this was 1954, people could smoke on planes, but not during take-offs or landings! That would be unsafe.
However, the captain did not turn enough, and crossed the localizer (the beam that guides the plane to the centreline of the runway) passing east of the outer marker, when he should’ve gone over it. He continued straight until the first officer, probably done with the checks, gave a hand signal to make him turn left more, which he did. Around this time, the speed was around 195 knots, 5 knots too fast to lower the flaps, but the captain lowered them anyways, and also had the plane at 5500 feet.
During this turn, the plane past by the outer marker 4 miles north of it. They called the tower around this time, 9:23pm, to report their altitude at 4000 feet and were moving away from the outer marker. This was a surprise to the tower, as they thought that they reported at Ash at 3000 feet, and asked them to confirm “four”, which they did. Eventually, the plane was brought out of its winding turn, crossing the localizer again at 165 knots IAS and 4000 feet. The captain then lowered the landing gear. The tower then called at 9:25 to say that another TCA plane landed, and had a cloud ceiling of just 300 feet “ragged”. A minute later, the Toronto ATC Centre issued its second and final clearance, saying that the aircraft was number one on the approach, was cleared to the airport for an ILS approach on runway 10, and was to report when leaving 3000 feet.
Around this time, the captain started his final turn to the right to line up with the localizer. The IAS was now at 135 knots, and, halfway during this turn, the first officer called the tower at 9:29 to say that they left 3000 feet. The plane continued to descend at around 600 feet per minute, or 10 feet per second. When they first reached the localizer, they were at 2500 feet, and the time was shortly before 9:30. The captain had to adjust a bit, as he overshot the localizer slightly, but he got it back on course. His location was over 9 miles from the outer marker, when normal procedures say that they should’ve lined up for it 3 or 4 miles from it, 5 in the most adverse conditions.
Nevertheless, they were finally following the localizer beam towards the outer marker. However, they kept descending, and at 2000 feet, they should’ve levelled off until they hit the glideslope (which helps guide the plane down to the runway with the right angle), as per regulations. As they neared 2000 feet, the first officer called the tower to tell them of their altitude. The time was now 9:31. When his put down his microphone, he saw something troubling: the altitude was now 1800 feet. The captain was still descending. The first officer, sticking to standard operating procedure of the time, pointed to the captain’s altimeter, particularly to the “2”. The captain simply nodded his head, gave a thumbs up while still holding the yoke, then told him to do the “before-landing” checklist.
This checklist took the first officer about 45 to 50 seconds to complete, holding it in his hand and blocking his view of his instruments. After the first officer is done with his checklist, he puts it down, and sees a few extremely troubling things: the glideslope needle pointing fully up, meaning that they were still under the glideslope; the airspeed was at 130 knots; and the scariest of them all, an altitude of 850 feet, as he recalls in a Toronto Star article, written by Katie Daubs near the 60th anniversary. Panicked, he then looked at the green ADF needle, realized that they still hadn’t crossed the outer marker, and yelled to the captain that they weren’t there yet. It was too late; the terrain in that area was at 800 feet above sea level, and they were descending at a rate where a recovery was all but impossible. Nevertheless, just before the crash, the captain reacted to the first officer’s yells and pulled back, allowing the plane to crash onto its gear rather than with its nose, as the first officer tells in the same article.⁷ They hit the ground on a snow-covered farmer’s field 12 seconds after 9:32pm.
As they hit the ground, they also struck trees. The captain, not knowing how damaged his plane is, decided not to climb away, and keep this unintentional crash landing going. The plane then hit a large tree, luckily not hitting the fuselage directly, but hitting the right wing, ripping it off. The plane then continued to slide until it came to a stop. Despite the crash, everyone on board somehow survived the impact. However, the first officer was knocked unconscious by the impact with the large tree, and almost everyone was injured by the impact and “flash fire” that occurred after the plane came to rest. Luckily, despite the injuries suffered by everyone, all of the passengers were able to escape under their own power. When the flight attendants did a headcount, they got to 21 people. The first officer and flight engineer were still on the plane, both possibly just regaining consciousness in a very dazed state. Captain Norman Ramsay, flight attendant Irene Deruche, and passenger Samuel Young⁹ went back into the burning wreckage, and managed to drag them out.⁸ After that, the plane exploded, while people in nearby farmhouses started helping out the survivors. When all was said and done, there was a headcount of 23 out of 23. Everyone is alive, and eventually taken to various hospitals to recover (some were allowed to go home after a check) after ambulances made the journey from Brampton to the farm via Highway 7, now called Bovaird Drive. A miracle just a week before Christmas. Some would have to go through a lot of hospital care, but still, alive.
The extra miracle on top of this miracle was that it crashed in a farm. Had the plane crashed anywhere from 15 seconds⁷ to a minute later,⁸ it would’ve crashed directly into downtown Brampton, which would’ve killed people on and off the plane. This fact did not go unnoticed by the town, as they were really displeased with the fact that the approach to runway 10 went directly over them. There were still the memories of Elizabeth, New Jersey, where, in a span of less than 2 months in 1951–52, three planes crashed into the city, two after take-off from Newark Airport, and one that was attempting to land there. Brampton wanted to avoid that fate, and advocated to move the ILS from runway 10 to runway 14. Eventually, plans to extend runway 14/32 in preparation for the jet age would move ILS landings to that runway, making Brampton clear of those approaches.
Now for the real question: why did the pilots crash 11 miles short of the runway? Was there something wrong with the plane? Did the pilots think that the Brampton lights were the runway in the poor weather? Were the instruments broken? As this was a serious crash of the newest plane in the fleet of Canada’s flag-carrier, a “Board of Inquiry” was called by George Marler, the Minister of Transport. According to Harvey Hickey’s article in The Globe and Mail on the release of the final report, the chairman of this Board was Donald W. Saunders, district superintendent of air regulations for the Department of Transport at Toronto. The two other board members were Dr. John J. Green, an aeronautical engineer with the Defense Research Board, and Group Captain Zebulon Lewis Leigh, Canada’s first instrument-rated airline pilot, and was one of Trans-Canada Air Lines’s first ever pilots when the airline was created in 1937, though he had resigned in 1940 to join the RCAF.¹⁰ John J. Green has a connection with CASB member Frank Thurston. Green was a Canadian delegate to NATO’s AGARD, and Thurston replaced him as a delegate.¹¹
Investigators from the Department of Transport were on the scene the next day, looking at the wreckage. As this was 1954, there was no CVR nor FDR to recover, requiring testimony from the flight crew, the passengers, and the controllers to figure out what happened. However, talking to the captain was not possible initially. After the adrenaline rush of rescuing his crew members, he was being treated in hospital for a number of days, suffering from severe shock, a fractured skull, a broken jaw, and chest and thigh injuries, which makes his rescue of his fellow crew members even more impressive. They also looked at the records from the tower, where they hit a wall. While they could interview the tower controllers, the tower’s recorder was broken, and had been broken for three days without anyone noticing. The recorder itself was only inspected once a week, so they did not get any exact details of communications between the tower and the plane. They did have written records from the controllers done when they realized there was a crash. In the words of the report, “these were not completely satisfactory,” and there were contradictions made by the controllers and the pilots that could not be rectified. They ended up recommending that these recorders not only be inspected more frequently, but also be upgraded to record the “two-way communication” between planes and controllers. Even if these recorders worked, they only recorded the outgoing messages, which the Board believes was inadequate.¹
After eventually talking with the crew, who found nothing wrong with the plane, noting the approximate times and locations of the plane, talking with the controllers, and noting that the ILS system for the airport was functioning properly when planes 7 minutes before the crash and 50 minutes after the crash used the same system to land normally, the Board of Inquiry released its report around February 22nd, 1955,¹² just two months after the accident, an extremely quick turnaround time for a major accident. In my opinion, the conclusion made in this report is shameful and, despite the original intentions of holding a full public inquiry after this Board of Inquiry, Marler decided not to do that. The reason? According to Harvey Hickey, “since the inquiry had been so exhaustive and because of the positive nature of the findings, he believed no useful purpose would be served by a public inquiry”.¹⁰ I fundamentally disagree with this assessment.
The findings in this report essentially say that the first officer was as aware of the flight as he could’ve been, given he had to do checklists during the approach that would’ve drawn his attention away from the instruments, and even gave corrections to the captain when he saw things go astray. On the other hand, the captain:
- “showed poor airmanship in the execution of his approach pattern, in that he made inadequate allowance for the strong prevailing wind and failed to utilize the ADF receiver to home on the outer marker”;
- “failed to carry out an approved ILS let-down and, in so far as the position and the altitude of the aircraft were concerned, he ignored the indications of the ADF needle tuned to the marker, the ILS glide path and the altimeter”;
- “ignored the warning from his first officer that he had descended below the regulation height”;
- “was under the impression that he was very much closer to the airport than he actually was”; and
- “broke the regulations regarding the minimum altitude at which the glide path is to be intersected, the minimum altitude at which the outer marker is to be crossed, and the minimum altitude to which the aircraft may descend on the approach at Malton without becoming contact [when they can see the runway], and continued his descent until he flew into the ground.”
Given all of this, under the probable cause section, it only read this: “The Board of Inquiry found that the accident was caused by negligence on the part of the captain.”¹
I have a lot of trouble with this “probable cause”. The word “negligence” is a really harsh word, and to use that word implies that captain was breaking all of the rules intentionally, which is impossible to know based on their investigation. It doesn’t explain what even happened, nor how it happened. Also, it is based on the findings, which only tell “what happened”, but does not explain the “why”. The findings are also missing one very crucial piece of the puzzle that could’ve explained the “why”, but the Board bizarrely brushed off: duty time.
Let’s look at the duty time noted in the report. The plane and crew started at Dorval for the start of the reverse flight, presumably flight 660, though I am not sure. They left Dorval at 9:02am. According to the report, the crew must report for duty one hour prior to departure, giving the crew a start time of around 8am. Factor in travel time and breakfast, the crew was up probably before 7am. They got to Malton Airport at around 10:35am, and, after about an hour on the ground, left for Tampa at 11:57am, arriving there at 4:43pm. At this point, they’ve been on duty for almost 9 hours. After an hour and 20 minutes on the ground, flight 661 left Tampa at 6:10pm. The plane, making record time to Toronto due to the strong tailwinds, eventually crashed at 9:32pm. At the moment of the crash, the crew was on duty for 13 and a half hours, with 9 hours and 41 minutes in the air.
In today’s aviation, that is an unacceptable amount of duty time, and breaks the current Canadian regulations. What makes this worse is that, after landing at Malton, they were supposed to continue back to Dorval, making a total planned duty time of around 16 hours. Despite this excessive amount of duty time, for the Board of Inquiry, they decided that it wasn’t a factor in the accident, as while this was considered a long day for the crew to be on duty, “pilots do not consider it to be particularly arduous provided that adequate rest has been secured prior to the flight.”¹
Meanwhile, in the real world, the Canadian Air Lines Pilots’ Association (CALPA) rejected the ruling, and they stated that “Today, the industry, world-wide, is faced with a problem described as pilot fatigue. Many countries, in recognition of this problem, have legislation limiting the hours of flying on hours of duty of a pilot per day, week of month.” They believed that, or at least the CALPA president implied that, the actual reason behind the crash was “fatigue induced by overwork.”¹³ Let’s look at the captain’s work schedule, according to Minister of Trade C.D. Howe, sourced from an article in the March 29th, 1955 issue of the The Globe and Mail by George Bain:
- On vacation from November 19 to December 11.
- December 12th, on duty for 14 hours and 2 minutes (10 hours and 27 minutes in the air), off for 16 hours and 17 minutes;
- December 13th, on duty 12 hours and 32 minutes (9 hours and 54 minutes in the air), off for 33 hours and 15 minutes;
- December 15th, on duty for 17 hours and 29 minutes (13 hours and 19 minutes in the air), off for 27 hours and 30 minutes;
- December 17th, on duty for 13 hours and 30 minutes (10 hours and 13 minutes in the air) before he crashed. Had he finished this flight, his duty time would’ve reached 16 hours and had an “in the air” time of about 11 hours and 45 minutes, before having 8 days off for Christmas.¹⁴
Almost all of these duty times are unacceptable on their own, and, assuming the captain actually made it to Malton and then to Dorval, his duty time would’ve exceeded 60 hours in just 6 days while assigned a duty period greater than 12 hours, breaking another set of current Canadian regulations.
The claims made by Howe that, with the captain sharing duties with the first officer, flight engineer, and the autopilot, “the fatigue is not particularly serious”¹⁴ on long flights is just not correct. The captain may not have felt tired, as stated in the report, but fatigue can come in many forms, and it could be unnoticed. You may not know that you are fatigued until you are extremely fatigued, and this unnoticed fatigue can still degrade a pilot’s job, even if they’re sharing duties. Monitoring instruments during an autopilot phase of flight can itself be mentally tiring. Though the science on pilot fatigue was, at best, basic in 1954, a public inquiry would’ve at least tried to source, and possibly fund, fatigue studies to see how easy it is for a pilot to get fatigued with the amount of hours the captain was on duty for that week, and how degraded their abilities can get.
To quote the Wikipedia article on “pilot fatigue”, sourcing from John Caldwell’s 2012 paper “Crew Schedules, Sleep Deprivation and Aviation Performance”, “symptoms associated with fatigue include slower reaction times, difficulty concentrating on tasks resulting in procedural mistakes, lapses in attention, inability to anticipate events, higher toleration for risk, forgetfulness, and reduced decision-making ability.” Sounds a lot like what was going on with the captain, with him missing his turns and having a sloppy entry onto the localizer. The thing that makes me believe that he was dealing with fatigue was that, according to his testimony, when the first officer pointed out the altimeter at 1800 feet, he read “2800 feet”, which would’ve made him think that he could descend more. That’s a huge sign that he was fatigued.
I find it unacceptable that the Board of Inquiry brushed his long duty time aside. This accident could’ve been a watershed moment for fatigue analysis, and prompting it without the loss of life! Instead, it gets swept under the rug to affect more pilots throughout the years until more fatal accidents happen and actual independent investigations can show that fatigue increases the risks of accidents happening. In my opinion, this wasn’t investigated further because of the people on the Board, particularly the chairman, Donald W. Saunders. He was the district superintendent of air regulations for the Department of Transport at Toronto. He would be very reluctant to say that his own department’s air regulations on pilot duty time were extremely lax and unsafe.
Ignoring fatigue as a factor in this crash and blaming “negligence” only makes Dr. Smirle Lawson’s words ever truer. Lawson, Chief Coroner of Ontario at the time stated, just 3 days after the crash, that “an independent board of aeronautical engineers should conduct the investigation, not officials of the department of transport.”¹⁵ He also stated that:
“Investigators from this department bend over backwards to support the government of the day, but I have never found them willing to have the facts brought out if those facts might embarrass the government. After all, they are civil servants and they are trying their own company. You can hardly expect a fair judgment from them. … On the basis of my experience with the department, nothing constructive will come of the present inquiry.”¹⁵
I pointed out pretty much these exact quotes made by Lawson in the prologue of Part 1 of my series “The State of Canadian Aviation Investigations” just as a point to show that Canada’s lack of an independent air accident investigative agency was already talked about in 1954. Now seeing the quotes in the full context just makes his quote prophetic.
With all of this ranting about the lack of research or thought into pilot fatigue, you may think that this report is completely useless. Somehow, that is wrong, and the recommendations points to something that I didn’t think was noticed until decades afterwards. In the recommendations, it talks about how the standard operating procedure for the first officer to merely point out corrections to the captain when the captain is flying is “unacceptable when an emergency exists, and recommends to Trans-Canada Air Lines and all other operators that consideration be given to a method of inter-communication between the crew which shall be more positive and less subject to inattention or misunderstanding at such a time.” They believed that, when the first officer noticed that the plane was at 850 feet, he should’ve had permission to pull up himself, and not just yell at the captain to pull up. At the time, it wasn’t standard procedure for the first officer to take controls in an emergency when the captain was not doing anything to get out of it. This issue leads to the report discussing the relationship between the captain and the first officer in general, and how the tradition of the captain being one with extensive experience and the first officer is the junior in the cockpit is, “to some extent, … as it should be”, according to the report, has also
“led to a condition* where the first officer has some hesitation in interrupting the captain to say or do anything which might be taken as a criticism of the performance of his captain. Particularly is this the case when the captain is involved in concentrated flying as during an ILS approach, and it is believed that many first officers have been reprimanded for interrupting the captain at such times. Under these circumstances, therefore, for a first officer to take over the controls from the captain to avert disaster would be considered a drastic step.”
Another place where this relationship should’ve been stronger was when the first officer pointed at the altimeter at “1800 feet”. The captain only responded by nodding his head and raising his right thumb. What should’ve happened is that the first officer actually says “We’re going below minimums, captain. We’re at 1800” while pointing at the altimeter, to which the captain responds by actually assessing the situation, verbally acknowledging the safety concern, and then actually responding to it with the first officer observing it all. Only at the point where the captain either reaches 2000 feet or meets the glideslope (whatever comes first) should the first officer then do the “Before Landing” checklist. Instead, the first officer trusted the captain to do the correction while doing the checklist, while the captain in his fatigued state continued the descent, not monitoring his instruments and not realizing just how far they were from the outer marker or the runway.
Seeing this blatant safety issue, the Board recommends that the airlines “re-examine this problem” of first officers having the hesitation of correcting the captain and try to see if there’s a better method for defining the “responsibility of the first officer to his captain when the safety of flight is in question and corrective actions are to be taken”. Today, we can say that the Board of Inquiry was trying to have the airlines come up with the system of Crew Resource Management (CRM), and train their pilots to use it. Unfortunately, that term would not even be invented for another 25 years, when the crash of United Airlines flight 173 would finally prompt aviation experts to try and find that method. Unfortunately, in the mess that followed the release of the report, the arguments on whether “negligence” was a cause and the lack of regard for “pilot fatigue” took over the conversation, and no one was in a position to advocate for airlines to look into re-examining the problem of the relationship between a captain and a first officer.
To conclude the story-telling, when the Board of Inquiry’s report came out, Norman Ramsay’s license was suspended for a period of time, after already being grounded by TCA after the accident. After the suspension, he joined Maritime Central Airways. Two years later, on August 11th, 1957, he would be the captain of Maritime Central Airways Flight 315. As he was flying towards Montreal, he flew into an active cumulonimbus cloud, a big no-no in aviation. Severe turbulence from the cloud would result in the pilots losing control, crashing 7.2 km west of Issoudun, Quebec. All 79 people on board died, which made it the deadliest aviation accident in Canadian history at the time, and is still currently the fifth-deadliest. The cruelest finding of that accident? The crew was on duty for almost 23 hours, over 19 hours of which in the air.¹⁶ Somehow, Norman Ramsay fell victim to pilot fatigue in an air accident again, and this time, it killed him. Had the Board of Inquiry took pilot fatigue seriously in 1954, it could’ve prevented that accident.
Gary Anderson, the first officer, would continue to fly with Trans-Canada Air Lines, and then Air Canada, until he retired in 1991, enjoying a 40-year long career as a pilot. Unfortunately, on December 31st, 2021, he died at the age of 89 at home. He was married for 62 years, and had three children and seven grandchildren, according to his obituary. He was only able to live out this life thanks to the heroic actions of Norman Ramsay, Irene Deruchie, and Samuel Young, who went back into the burning plane to drag him out.
The Super Constellations did not last for too long in TCA’s fleet. In 1956, TCA ordered four jet engined Douglas DC-8s (expanding the order to 11), which marked the start of the jet age for Canada when they delivered in 1960. The quicker and quieter DC-8s swiftly replaced the Super Constellations on the European and transcontinental routes, pushing the Super Constellations on southern and Caribbean routes.⁴
While TCA’s commitment to an “all-turbine” fleet by 1961 would’ve completely eliminated the Super Constellations from the fleet, covering short-to-medium routes with turboprops, specifically Vickers Viscounts and Vickers Vanguards, maintenance troubles with the Vanguards meant that TCA kept two Super Constellations on standby until 1963. However, after that, they were completely gone, less than 10 years after their exciting arrival.⁴ Today, only one Super Constellation with a TCA livery still exists. Registered CF-TGE, it is on display in the Museum of Flight in Seattle, after initially being a conference facility, a restaurant and a cocktail lounge at or near Toronto Pearson Airport.
Looking at the overview of this accident and report, I truly believe that it was both a Christmas miracle and a Christmas debacle. The true debacle, however, was not the captain’s actions, but was the investigation’s lack of appreciation of pilot fatigue, possibly due to bias from the Board. This could’ve been an important investigation in not just Canadian aviation history, but in world aviation history. It could’ve pushed the need to study pilot fatigue much more closely, advancing human factors much earlier than it actually was. It could’ve heavily pushed for the need for first officers to be more equal in the cockpit and kickstarted the research into CRM 25 years early, saving even more lives.
Instead, we get a pathetic excuse of a report that pushes all of the failures of aviation regulations onto one fatigued and unlucky captain. A pathetic excuse of a report that is meant to stand in for a full public inquiry. A pathetic excuse of a report that only slightly nudged safety in the right direction (if at all), when it could’ve excessively pushed safety to levels far beyond what was thought possible. I get that air accident investigations were not yet at its modern form, but still, Canada could’ve had a huge head start. Instead, it had to have a wild history of aviation investigations that required five long articles just to get to the point where Canadian investigations were seen as some of the best in the world. It was a lost opportunity, which could be the slogan of Canadian aviation in the 1950s, with the lost opportunities of the Avro Jetliner and Avro Arrow occurring around that period as well.
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If you made it this far, thank you! I really wanted to make the article as there doesn’t seem to be much information on this accident, to the point where the flight number is unknown (and listed incorrectly on the BAAA information page), yet it happened in a city I once lived in. The 70th anniversary of this accident is this December, so I am hoping for articles marking that anniversary to have the flight number at least.
This accident seemed to have a bit more to it than I expected, and I believe that I might be the first one since CALPA, 69 years ago, to push for the idea that Norman Ramsay was fatigued and overworked, leading him to make many mistakes, a concept that seemed to be poorly understood in 1954. I hope this idea starts to catch on, and mostly exonerates him of his actions in the history books.
Shoutouts to the Canadian Aviation Historical Society (and Peter F. Marshall in particular) for writing about TCA’s Super Constellations! I also used many old articles from the Toronto Daily Star and The Globe and Mail. If you want to see those sources, let me know, and I’ll try to send you them. I added numbers to match with the sources here.
