The Hoffar Motor Boat Company’s H-2 hydroplane crashed into a house on Vancouver’s Bute Street on September 4, 1918. Vancouver Archives.
Accident investigation in the United States had its origins in 1915 with the U.S. National Advisory Committee for Aeronautics (NACA), which formalized investigation methodologies. From April 1917 to November 1918, the United States, despite being a late entry in the war and because of its industrial might, had its aircraft manufacturers deliver 13,984 aircraft to its military. Had the contracts continued into 1919, the manufacturers would have turned out 21,000 more aircraft the following year.[2] But if anything, the huge stockpiles of surplus aircraft proved a detriment to investing in new designs. The JN-4 aircraft and OX-5 engines still in their crates were given away at bargain prices, retarding the development of safer aircraft being built because they couldn’t compete pricewise.
When air mail in the United States was initiated in 1918, the U.S. Post Office Department was given the responsibility for aircraft inspection and regulations, some of which, like making pilots carry a heavy revolver when flying, had originated in the days of the Pony Express. The aircraft were war-surplus, licence-built De Havilland-4s (DH-4s). No safer, or more lethal, than their contemporaries, the DH-4s were called “Flaming Coffins” for good reason. The pilot sat sandwiched between the engine and the fuel tank, and after repeated rough landings, the fuselage’s wooden longerons splintered, pushing the fuel tank up against the pilot and engine and splashing gasoline onto the hot exhaust manifolds. If that didn’t kill him, what eventually did was the engine’s exhaust pipe, which ran alongside the gas tank. When cracked after too many landings, the pipe ignited the doped fabric. Since both pilot and aircraft were incinerated, the cause of a crash remained a mystery.
Jerome “Jerry” Lederer joined the U.S. Post Office’s Air Mail Service in 1926 as an aeronautical engineer, beginning a lifelong interest in flight safety. When interviewed in September 2001, he recalled:
When we lost all those Air Mail Service pilots in the early 1920s, the usual cause of death was a fire following a crash. We built a concrete ramp with a concrete wall at the end of it, put these ships under full power, and let them go down the ramp into the wall. Slow-motion pictures showed that when the airplane crashed, the fuel spilling out of the tanks — which were carried up front in the fuselage — would go onto the hot exhaust manifold and start the fire. I drew specifications for new parts and developed test methods for new ways of operating the plane.[3]
Lederer reconstructed wrecked aircraft to determine why they had crashed. Risk management, he later said, was a more realistic term than safety, since it implied that hazards were ever-present and they had to be identified, analyzed, evaluated, and controlled — or rationally accepted.[4]
Because these were the earliest cross-country and after-sunset flights in North America, it was the first time that pilots had to contend with darkness, weather, visibility, and navigation. Flying on schedule whatever the weather or time of day or night gave birth to the world’s first system of scheduled air transportation. Cross-country flying depended very much on visibility, and if an aviator wished to survive, he learned to read the earth and sky around him — when he could see both. As air mail pilots in Canada later learned, if they flew low enough and relied on the “iron compass” — the railways (stations had place names painted on the roofs), roads, and landmarks — they would find their way through.
Postwar flying was still “seat-of-the-pants.” If the pilot heard his engine labouring, that meant the aircraft was climbing. When caught in overcast conditions and flying blind, a pilot listened to his wires and engine. If the former were ringing, that meant his speed was going up and he was aimed at the ground. If he wished to complete his flight safely, the aviator would know all the farms, golf courses, and racetracks where he could land when his engine routinely cut out. Cows were his weather vanes, since they turned their tails to the wind. In the event a pilot’s compass failed, he had a sure way to determine direction: remember that rural outhouses always faced south.
Long before multiple VHF omnidirectional ranges (VORs), global-positioning receivers, and on-board computers, cross-country pilots navigated by a little black book. A barnstormer before he flew the U.S. mail, Elrey Jeppesen suffered the lack of navigational aids along his routes — all that air mail pilots were supplied with were Rand McNally automobile maps — and soon began jotting down in a notebook the location of railway lines, smokestacks, and water towers en route, as well as the phone numbers of local farmers willing to tell him what the weather ahead was like. On his days off, Jeppesen climbed those water towers with an altimeter to measure their height and checked out convenient pastures that could be used for forced landings. Other pilots watched him fill his notebook, and when he was persuaded to publish the contents, his inventory of navigational information became a “bestseller” among the flying community. Thus began the inception of standardized life-saving aerial charts (still called “Jepp charts”) that pilots even today couldn’t fly without.
Going one step better to make sure their flying mailmen were aimed in the right direction, the U.S. government laid down hundreds of 70-foot yellow concrete arrows along the route, each positioned next to a 50-foot metal tower with a rotating gas-powered light. The arrows pointed the way during the day, while the beacons did the same at night. It was thought that on days and nights when visibility was unlimited, both could be seen by lost pilots from 10 miles up.[5]
Flying at night and in poor weather did force aviation authorities to experiment with radio and teletype. In response to several plane crashes, 10 radio stations were installed in 1921 along the New York–San Francisco air route to transmit weather forecasts. The U.S. Navy Weather Service was already distributing weather information to mariners in weekly notices, and this data was adapted for the air mail program for use on the teletype machines of the day. Because early teletypes transmitted information slowly and required the volume of transmitted characters be kept to a minimum, coded contractions became part of the format, hence the NOTAM language that remains in use today.[6]
The earliest form of rudimentary control and pilot safety was where all flying began and ended — at the airfield. During the First World War, to signal takeoffs and landings, a “controller” stood on the field or roof of the nearest shack with a set of flags. He waved a green or checkered flag to tell the pilot to go, and a red flag to hold. Since this signalling system was useless at night, in poor weather, or beyond visual range, some airports had hand-held lights that aimed red or green beacons at incoming or departing pilots, a system that continues in emergency use today. But once the aircraft was out of sight, as with a sailing ship a century earlier, no one knew its progress until it arrived … somewhere. If it crashed, unless this took place in a populous area, the chances of finding the wreckage, let alone figuring out why it did so, were nil.
The evolution of airports in Canada: without paved runways, lighting, or radio until the Trans Canada Airway, airports were poorly equipped for commercial aviation. Library and Archives Canada.
When the U.S. government surrendered air mail operations to private companies in 1925, out of the 40 pilots originally hired, only nine were still alive. Not for nothing was it called “The Suicide Club.” Because of this horrendous record, with the Air Commerce Act in 1926, the U.S. government legislated into being under the Department of Commerce a national accident investigation department and Congress charged its Aeronautics Branch to investigate and to “make public the causes of aviation accidents.” The Committee on Aircraft Accidents issued Technical Report No. 357 on October 3, 1928, entitled “Aircraft Accidents: Method of Analysis,” defining the terminology and classifications of accidents to be used. An aircraft crash could always be counted on to increase newspaper