Investigation Summary
The aircraft, named Ticino, was performing a scheduled flight from Geneva to London. It had previously flown the reverse route from London to Geneva earlier that day. Before departing Geneva, fuel had been ordered but, for reasons not fully determined, was never delivered to the aircraft. The flight crew failed to verify the fuel state via the cockpit gauges or follow the pre-departure checklist, departing with only the residual fuel from the previous leg. While cruising at 12,000 feet over the English Channel, the port engine failed. The crew feathered the propeller and initiated a diversion to RAF Manston, but the starboard engine failed shortly thereafter. The captain successfully ditched the aircraft approximately 1.5 miles off Folkestone. Because the flight was scheduled for a short crossing, prevailing regulations did not require life-saving equipment, and none was on board. The crew was later criticized by a coroner for failing to adequately assist the non-swimming passengers in the water after the ditching.
Final Conclusions
The Ministry of Transport and Civil Aviation concluded the accident was caused by the complete loss of power in both engines due to fuel exhaustion. This was attributed to the negligence of both pilots, who failed to ensure the aircraft was refuelled and failed to monitor fuel gauges. The three fatalities were specifically attributed to the lack of life-saving equipment on board to support passengers after the successful ditching.
Photographic Evidence (1)
Video Analysis
No video analysis linked for this case file yet.
Airframe & Maintenance
Systems & Failure Modes
Fuel Gauges
Instruments intended to show the quantity of fuel in the tanks; the crew failed to monitor these during pre-flight and the early stages of the flight.
Life-saving Equipment
Life jackets and rafts were not carried on this flight as the crossing time was less than the 30-minute regulatory threshold for mandatory carriage.
Interesting Facts
- 01The aircraft was not refuelled at Geneva despite fuel being ordered.
- 02Regulations at the time only required life-saving equipment for water crossings exceeding 30 minutes.
- 03All nine occupants successfully exited the aircraft after the ditching.
- 04The three fatalities were British passengers who could not swim.
- 05The aircraft was sold to Swissair by KLM only seven months prior to the accident.
Safety Actions & Advisories
Equipment Policy Change
Following the accident, Swissair implemented a policy to carry life-saving equipment on all cross-Channel flights, regardless of the duration over water.
Personnel Action
Both the Captain and the First Officer were suspended and subsequently dismissed from Swissair once the cause of the accident was confirmed as negligence.