Investigation Summary
On May 13, 1912, aviation pioneer Edward Victor Beauchamp Fisher was conducting a flight with American millionaire Victor Mason as a passenger. After completing two circuits of the Brooklands flying ground, the aircraft initiated a left-hand turn while flying in a tail-low attitude. During the turn, the aircraft side-slipped and entered a stall at an altitude of approximately 100 to 200 feet. The Royal Aero Club investigation determined that as the aircraft lost control, the pilot, who was not strapped in, was thrown forward onto the elevating gear. This involuntary movement provided a sudden nose-down input that caused the aircraft to dive vertically and simultaneously ejected the pilot from his seat. Fisher was thrown clear of the aircraft before it struck the ground head-first. The wreckage burst into flames upon impact, killing Mason, who remained trapped in the fuselage. The Royal Aero Club's Public Safety and Accidents Investigation Committee, formed only months earlier, conducted a rigorous inquiry that included witness testimony, consultations with manufacturers, and medical evidence from an autopsy.
Final Conclusions
The Royal Aero Club Public Safety and Accidents Investigation Committee concluded that the accident was caused by pilot error. The pilot failed to appreciate the dangerous conditions of making a turn while the aircraft was flying tail-down and was not flying in a proper manner. The committee noted that had the pilot been suitably strapped into his seat, he might have retained control of the aircraft. The report was published in Flight magazine on June 8, 1912.
Video Analysis
No video analysis linked for this case file yet.
Airframe & Maintenance
Systems & Failure Modes
Elevating Gear
The flight controls used to manage pitch; investigators believed the pilot was thrown onto this gear, causing an involuntary nose-down input.
Green D.4 Engine
A 60 hp water-cooled engine; evidence showed it was running normally until the moment of impact.
Interesting Facts
- 01The accident resulted in the first-ever published aviation accident investigation report.
- 02The pilot, Edward Fisher, held Aviator's Certificate No. 77, granted a year prior.
- 03The aircraft was powered by a 60 horsepower Green D.4 engine.
- 04Investigators confirmed the fire was a result of the impact, not a cause of the accident.
- 05The pilot's body was found approximately 60 feet in front of the main wreckage.
- 06The accident was witnessed by a crowd of approximately 200 people at the Brooklands Aerodrome.
Safety Actions & Advisories
Pilot Restraints
The committee recommended that pilots should be suitably strapped into their seats to ensure they retain control of the aircraft during unexpected maneuvers or turbulence.
Standardized Reporting
The investigation established a formal structure (Facts, Analysis, Conclusions, Recommendations) that became the global benchmark for aviation safety reporting.