Accident at Shannon, Ireland, 15 Aug 1949

Accident narrative

On August 15, 1949, at 0240, a Transocean Air Lines DC-4 ditched in the Atlantic Ocean approximately seven miles northwest of Lurga Point on the Irish Coast after exhausting its fuel. The aircraft, operating as a nonscheduled flight from Rome to Shannon, Ireland, had flown past its destination. Of the 49 passengers and nine crew members on board, seven passengers and one crew member died from exposure or drowning.

**The flight**

The flight departed Rome at 1608 on August 14. The aircraft carried 49 passengers, a crew of nine, and 2,260 gallons of fuel. The crew included Captain Edward C. Bessey, First Officer Richard Hall, Second Officer John W. Moore, and Navigator James A. Baumann. Captain Bessey had 8,600 flying hours, including 2,500 in DC-4 type aircraft. All crew members had received a four-day rest period in Rome before the flight.

The crew arrived at the airport 30 minutes late. To conserve time, Captain Bessey divided the pre-flight duties. The navigator computed a flight plan based on a route to Shannon via airways over Paris, assuming 12 hours of fuel. The second officer prepared a flight clearance for a direct route to Shannon, indicating 16 hours of fuel. The crew members did not confer.

When they reported to the aircraft, they discovered only 11 hours of fuel (2,200 gallons) were on board. At the company's standard consumption estimate of 200 gallons per hour, this was insufficient for the required two-hour reserve after flying to Shannon and the designated alternate airport of Paris. Because weather was predicted to be relatively clear, the captain and crew decided the fuel was sufficient, changed their alternate airport to Dublin, and elected to fly direct from Marseille to Shannon. The change in alternate was not transmitted to Rome Air Traffic Control, and Captain Bessey did not examine the flight documents before takeoff.

First Officer Hall made the takeoff. After leveling off at 8,500 feet, which was 2,000 feet below the planned cruising altitude, Captain Bessey retired to the crew's quarters. Hall continued as pilot with Moore as copilot. Except for rough operation of the number 3 engine when the mixture was in auto lean, the flight proceeded normally.

**En route**

The flight reported over Marseille at 1820 and over Rennes, France, at 2050. Approximately 15 minutes after their estimated time of arrival over the French Coast, the coast was observed below. The navigator obtained a three-star fix, plotting their position a few miles north of the French coast.

Captain Bessey returned to the flight deck. First Officer Hall obtained a radio bearing on Brest and observed a second coastline ahead. Captain Bessey asked the navigator if they were just south of the Cherbourg Peninsula and if the Channel Islands were off to the right; the navigator answered in the affirmative.

At 2227, the flight transmitted to Shannon Radio that it was over Land's End, Great Britain. Shortly after, the flight descended to 3,500 feet and held a course of 310 degrees. The navigator received the Shannon radio range but inadvertently labeled the southeast sector of the range "A" rather than "N" on his chart. Receiving an "A" signal, he believed they had not yet passed Shannon.

After 0010, the flight proceeded at reduced power. Between 0030 and 0040, the navigator obtained a celestial fix that placed the aircraft 175 miles northwest of Shannon. At approximately 0050, the aircraft was turned to a heading of 130 degrees to return to Shannon.

At 0106, the flight alerted Air-Sea Rescue at Shannon, giving its position as 100 miles west of Shannon. The flight continued inbound until 0240, when all fuel was exhausted and the aircraft was ditched. An additional 60 gallons of fuel discovered in a fuselage tank had been consumed just before ditching. No use was made of 500 KC, the International Distress Frequency.

The aircraft remained afloat for about 15 minutes, during which the crew and passengers manned all but one of the life rafts. Aircraft circling overhead directed a British trawler to the scene, and rescue operations were completed shortly after daylight.

**What the investigation found**

Because the flight documents and navigational charts were lost when the aircraft sank, the Civil Aeronautics Board reconstructed the flight path using recorded radio transmissions, weather reports, and crew testimony.

The Board found that the crew's position reports seemed inconsistent with known facts. Based on the aircraft's weight, cruising altitude, and en route winds, the Board calculated the true air speed should have been at least 180 knots, resulting in a ground speed of approximately 181 knots. At this speed, the flight would have arrived abeam of Rennes at 2029, rather than the reported 2050.

The Board found it reasonable to conclude that when the flight reported over Land's End at 2227, it was actually over one of the narrow peninsulas of southern Ireland, such as Mizen Head. The Board noted that Land's End could be mistakenly identified as the Cherbourg Peninsula, and the Channel Islands confused with the Round Island group south of Land's End. The Board determined the flight progressed over its route much faster than was computed or realized by the crew.

The investigation determined that weather conditions were suitable for visual flight and that all radio facilities were functioning normally. No significant maloperation of the aircraft existed.

The Board found that the crew did not confer during flight planning and lacked accurate knowledge of the route, fuel requirements, or flight duration. Weather information obtained in Rome was for the route via Paris, not the direct route flown, and no attempt was made to secure updated weather en route. Furthermore, accurate hourly positions were not plotted, and celestial navigation was not used routinely even though the stars were visible at all times after sunset.

**Probable cause**

The Board determined that the probable cause of this accident was "the failure of the captain to exercise the proper supervision over his crew during flight planning and while en route."