Why Did Air Canada Flight 797 Plane Crash?
Air Canada Flight 797 was a passenger flight departing from Dallas-Fort Worth International Airport in Texas on June 2, 1983. The flight's final destination was Montreal, but it was scheduled to stop in Toronto before continuing east to Montreal. The aircraft that day was a McDonnell Douglas DC-9-32, normal configurations for that plane seat 90 passengers, and there were just 41 passengers on board for the flight, so it was a bit less than half full.
Who Were the Pilots and Crew on Air Canada Flight 797?
There were five crew members on board that day, including captain Donald Cameron and first officer Claude Ouimet. Both pilots were experienced with the aircraft; Captain Cameron had 13,000 flight hours with close to 5,000 of those flying a DC-9, and First Officer Ouimet had 5,600 hours of flight experience with almost half of those hours on the DC-9.
In addition to the pilots, Flight 797 had three flight attendants on board: Sergio Benetti, Laura Kayama, and Judith Davidson. They were a reasonably seasoned crew; Benetti and Davidson both had about 10 years of experience working as flight attendants for Air Canada, and Kayama had seven years of experience.
What Was It Like on Air Canada Flight 797?
Travel in the 1980s was, let's say, different than it is today. The 80s were a time of free checked luggage, no restrictions on cabin luggage, meals were often included with your ticket-- which you may have bought just moments before your flight-- and smoking was allowed on board. With the exception of smoking, there really wasn't a lot to dislike.
Air Canada Flight 797 had been in flight for about two and a half hours when the cockpit voice recorder caught a brief exchange that would, in hindsight, become the moment things started to go wrong. At 6:51 PM, First Officer Ouimet was having his dinner, and as he and Captain Cameron joked about the quality of the meal and the fact Ouimet would need to finish his food before Cameron could eat, Cameron heard three loud pops over his shoulder. It was nothing major: three circuit breakers had tripped. All three were connected to the lavatory at the rear of the aircraft, and neither pilot was concerned by them. The evening meal service was wrapping up in the cabin, and circuit breakers were more likely to trip at that point in a flight because so many people got up to use the restroom when they were done eating. Captain Cameron waited eight minutes before attempting to reset them to give the usage and traffic a bit of time to die down, although when he tried to reset them at 6:59 PM the circuits popped right back out. By this point, the pilots had surmised that someone must have flushed something that jammed the toilet, and there was no additional conversation about the issue.
What Went Wrong on Air Canada Flight 797?
Outside of the cockpit and in the main cabin, passengers were also beginning to notice something was off. Shortly after the circuit breakers tripped, a passenger seated near the lavatory let Judith Davidson know that there was a strange smell coming from the back of the plane. Davidson was quickly able to determine that the smell was coming from the lavatory; in fact, she opened the door to peek inside and could see some light smoke but did not see any flames or other signals that would clearly indicate a fire. It also didn't smell like a fire; one passenger who was seated near the lavatory, Connie Kirsch, said it smelled "wirey." She notified Sergio Benetti, who was the chief flight attendant that day. He went to the lavatory to investigate and also saw smoke but no flames; he sprayed the entire lavatory with a fire extinguisher out of an abundance of caution, but since there weren't any flames he couldn't be sure he put out whatever fire might have started in there.
As Benetti was fighting an invisible fire, just three minutes after the circuit breaker reset was attempted, Laura Kayama delivered Captain Cameron's dinner to him at 7:02 with a side of bad news: according to the flight recorder she said, "Excuse me, there's a fire in the washroom at the back, they just went back to go to put it out." Cameron decided to hold off on dinner and sent Ouimet back to investigate. As the captain was learning about the unidentified issue, the passengers were also quickly figuring out that something was wrong: smoke was beginning to fill the cabin, and the flight attendants began to move them toward the front of the aircraft to maximize the space between the lavatory, the smoke, and the people on board. At this point it has still only been a few minutes since the smell was first noticed and the first traces of smoke had appeared, so passengers were unquestionably concerned. Interestingly enough, Captain Cameron wasn't as concerned as you might expect. Smithsonian Channel's Air Disasters interviewed him for the episode they developed for Flight 797. Cameron said, "You've gotta remember, in 1983 people were allowed to smoke in the aircraft, and there had been a number of incidents in the industry, so it really didn't alarm me that much."
Ouimet was able to assess the situation and determined it was a good idea to make an emergency landing, but flight attendant Benetti had a different recommendation: he noted that the smoke was clearing a bit after he used the fire extinguisher, and he thought the situation was improving. Sure enough, the smoke didn't seem quite as bad as it had when Ouimet had investigated just a few moments before, so just four minutes after being alerted to the possible fire— it's now 7:06 PM— he took a pair of goggles and a mask and went back for a second opinion. Captain Cameron continued at cruising altitude since it was now looking like the fire was a bin fire, probably related to a cigarette that wasn't properly extinguished, and an emergency landing could be avoided.
That's when the master caution light came on in the cockpit.
The master caution light is one of those flashing red lights you just don't want to see in an aircraft flying 33,000 feet above the ground. The master caution indicates a loss of electrical power to the cabin, the unquestionable sign that there was something very, very wrong on board. Captain Cameron immediately noticed that many of the plane's instruments had gone offline, and he was left with what he called "primitive" instruments that provided basic control over the aircraft and were similar to those you might find on a World War II bomber— the plane was exceptionally difficult to handle and control, and it probably goes without saying that the ride was a lot less smooth and comfortable. He radioed to the air traffic controller in nearby Indianapolis to let them know there was an electrical issue impacting the aircraft, and moments later air traffic control noted that Flight 797 disappeared from their radar. The plane did not lose communication with ATC, though, which would prove to be a huge saving grace.
First Officer Ouimet returned from the lavatory and noted that during this trip it wasn't possible to even open the door because the handle was too hot to touch. At this point an emergency landing was inevitable; no sooner had Ouimet shared the bad news, the plane's emergency power was lost as well, and the cockpit voice recorder ceased to function. At 7:08, Cameron declared Mayday and was immediately granted clearance to land at the Cincinnati Airport, which was 28 miles away from the plane's location. They weren't that far away, but it was not going to be an easy descent or landing. The plane's main systems continued to fail, including a part called the horizontal stabilizer, which effectively froze the plane at its cruising altitude of 33,000 feet. Cameron was able to force the plane into a descent, but that process involved basically fighting the plane and using his body weight to push against the equivalent of 44 pounds of pressure the plane was thrusting back at him. It's an exhausting effort, and 28 miles is a very long time to sustain that kind of physical exertion.
Passengers on Air Canada Flight 797
28 miles is also a long time if you are in the cabin, which is where 41 passengers and 3 crew members found themselves. The plane had lost most of its electrical power at this point, and that meant the PA system wasn't working. The flight attendants had moved passengers to the front of the plane, but more and more dark smoke was flowing from the lavatory and even from the seams in the ceiling. It was getting very difficult to breathe, and that alone prohibited flight attendants from sharing information with the passengers. The flight attendants started handing out wet towels and instructing people to hold them over their noses and mouths when taking breaths. If you're wondering why they wouldn't just deploy the oxygen masks, they couldn't. Oxygen masks are used when the cabin depressurizes. If there is a fire on board, oxygen masks only add to the risk, because what feeds a fire? Oxygen. The one safety feature you think you can count on in this case is the one thing that could very quickly escalate the situation past the point of no return-- even though it feels tempting because there still is no visible fire on board. It's just smoke-- and the crew had no idea what was causing it. As the smoke and heat became almost unbearable, some passengers began making decisions such as putting on suit jackets or ensuring their personal identification was in their pockets to make it easier for investigators to identify them. Many people assumed they would not survive. Still, there were passengers who held onto optimism even in the face of uncertainty. Graham Wright, a businessman returning home to Toronto that day, told the New York Times, ''I didn't know whether we were going to put down on a river or a field or a runway. The pilot seemed to be in control. I felt sure we would make it. Somehow, the crew managed to convince everybody that we would make it.''
Emergency Exits on Air Canada Flight 797
There is one additional task that the flight attendants had to undertake, and that was teaching the people seated in the exit rows how to open the emergency door when the plane landed. In the 1980s, that kind of instruction was not commonly provided to passengers in the way that it is today, so as the smoke was filling the cabin several passengers were also tasked with trying to learn one last potentially lifesaving role they would fill if the plane was able to land safely enough that they could attempt to deplane.
Air Canada Flight 797 Landing in Cincinnati
As Air Canada Flight 797 approached Cincinnati and made its first contact with air control, the cockpit was also starting to fill up with smoke. To compound all of the issues they were facing— the plane's electrical failures, the loss of many instruments— the smoke was making it hard to see. Enter Gregory Karam, who was the approach controller in Cincinnati that day, had to provide them with complete visual guidance during the descent and landing. Captain Cameron could not see out of the windows in the final moments before landing, and once Karam had the plane in sight he told Cameron when to turn and when to descend. Cameron credited Karam with the plane's landing, later saying that, "We were steered to the airport by the most capable air traffic control controller whose voice I have ever heard." At 7:20 PM-- which is just 29 minutes after the circuit breakers first popped in the cockpit-- Flight 797 made a hard landing on the runway in Cincinnati and was greeted with fire trucks and emergency responders hoping to get everyone safely out of the plane. At this point, they are still not sure what is going on inside the plane.
Air Canada Flight 797 Survivors
Just because the plane was on the ground did not mean the danger was over. The plane slowed to a stop, but the smoke was so thick and dark that people were not able to see— and breathing was increasingly difficult. Flight attendant Sergio Benetti was the first person who was able to open a door and begin helping people off the plane, but disembarking was a slow process. Although they eventually got three of the doors open, some people inside the plane became disoriented in what was now pitch blackness, and while many people were able to feel their way toward the front of the plane and eventually into the light of day, others guided their way toward the back of the plane instead.
In the cockpit, First Officer Ouimet escaped by jumping from the window 16 feet to the ground below him. Captain Cameron did not follow him; after fighting the plane for 28 miles from the start of the emergency descent until touchdown he was exhausted, disoriented, and unable to move out of his seat. Ouimet saw the pilot looking dazed and slumped over the wheel and shouted for firefighters to soak him with foam in the hopes it might shock him back into action. That request, and the firefighters’ compliance, saved his life; the foam was freezing cold and roused him enough that he could climb out of the window and fall to the ground below.
Air Canada Flight 797 Victims
By 7:22 PM, about 90 seconds after the aircraft's doors began to open, 18 passengers and all 5 crew members had made it safely out of the plane. Captain Cameron was the last person who made it out alive; moments after his escape, a flash fire consumed the entire interior of the plane's fuselage, trapping all other passengers inside and ending 23 lives. As the fire burned it produced toxic, combustible smoke that collected in the cabin, and once the doors began to open they connected with an endless supply of fire's best friend: oxygen. When the smoke, fire, and oxygen connected, the flash fire was unstoppable. It took less than two minutes for those conditions to occur.
That's how Air Canada Flight 797 ended on June 2, 1983: an emergency landing, a fiery blaze, and 23 passengers who lost their lives.
There were 41 passengers on the plane, including Graham Wright and Connie Kirsch. They were also joined by Randy Morris and his wife Lisa Ehrich from Texas, who were en route to Europe to celebrate their third wedding anniversary. Many of the survivors gave interviews, including several who were interviewed by local news outlets from their hospital rooms.
Of the 23 people who were lost that day, 21 were Canadian citizens and two were US citizens. One passenger was particularly notable: Stan Rogers, who to this day is a recognized folk musician, did not make it off the plane. To this day his music is celebrated and often covered by fellow artists, and his legacy lives not only through his musical contributions but through those of his son Nathan, who was just four years old when Stan passed away.
Air Canada 797 Crash Investigation
The initial investigation is nightmarish for the NTSB, who included a diagram indicating where both survivors and victims were located based on where they were seated during the final descent in their accident report. Investigators noted that some people were found seated with their seat belts on; they may have passed away or become asphyxiated from smoke inhalation before landing. Others were found on the ground in clear attempts to locate an exit, suggesting some people survived the landing but perished when the flash fire consumed the fuselage. Blood samples taken from the victims confirmed that cyanide, fluoride, and carbon monoxide were present in their systems and likely contributed to the cause of death.
The interior of the plane was a complete loss, which made it difficult for investigators to confidently determine the cause of the fire. In the early days of the investigation the FBI was involved because terrorism was suspected. However, they did not find any evidence of an explosive device or any other object that might have contributed to an intentional fire, so the FBI concluded it was accidental and turned the investigation back to the NTSB. When it came to accidents, there were a few possibilities. Specifically, the NTSB focused on what the pilots suspected from the very beginning: a cigarette left to burn in the lavatory's trash bin. Although the lavatory was significantly compromised by the fire, investigators were able to locate the trash bin and found that its interior was somewhat intact; there were pieces of paper inside that had not burned, which was inconsistent with a fire starting in the trash bin. They were able to rule out cigarettes as the cause of the fire.
The NTSB found that the plane had 76 different maintenance issues noted in its logs, which is a high number for most aircraft. Additionally, and perhaps most telling, an explosive decompression in the plane's bulkhead had contributed to the need for an emergency landing just four years earlier. The ensuring electrical damage to the plane was repaired, but a flawed or faulty repair job could have contributed to the issue that took down Flight 797. In addition, investigators zeroed in on the cockpit voice recorder, where they found another clue. About three minutes before the circuit breakers tripped, the recorder picked up eight separate sounds consistent with electrical arcs. Electrical arcing is incredibly dangerous; it happens when electricity jumps from its intended path, such as wiring, to a different path. It typically happens when electricity passes through old, frayed wires or when wiring has been poorly maintained or repaired. The arcing picked up by the voice recorder would not have been audible to Captain Cameron or First Officer Ouimet, but it did lead investigators to trace the sound to a generator located under the plane's lavatory. Unfortunately, it turned into a bit of a dead end: although the arcing sound was a good clue, investigators couldn't confirm that the arcing sound occurred before the fire itself started. That meant the fire could have started earlier or even elsewhere on the plane.
Air Canada Flight 797 NTSB Report
Ultimately, because the plane was so damaged, the NTSB released their accident report in August 1984 and concluded that the safety board could not determine the exact cause of the fire. That said, the report was very critical of the pilots. In part, the report stated a few almost controversial conclusions:
The source of the smoke was never identified either by the flight attendants or the first officer. The captain was never told nor did he inquire as to the precise location and extent of the "fire," which had been reported to him. Crewmember reports that the fire was abating misled the captain about the fire severity and he delayed his decision to declare an emergency and descend.
Because of the delayed decision to descend, the airplane lost the opportunity to be landed at Louisville. Had the airplane been landed at Louisville, it could have been landed 3 to 5 minutes earlier than it actually did land at Cincinnati. The delayed decision to descend and land contributed to the severity of the accident.
This was a survivable accident.
Air Canada Flight 797 Petition for Reconsideration of Probable Cause
For Cameron and Ouimet, the findings were devastating. Cameron later said, "All I know was that I did the best I could," "I'm very sorry the people that didn't get off, didn't get off, because we spent a lot of time and effort getting them there."
On December 20, 1984, the NTSB received a Petition For Reconsideration Of Probable Cause from the Air Line Pilots Association who went to bat for Captain Cameron. They specifically took issue with the NTSB's finding that Cameron delayed his decision to descend, which contributed to the loss of life on board. They specifically called attention to the fact Cameron received conflicting information from Ouimet and flight attendant Sergio Benetti, who each confirmed the conditions were getting better and suggested the fire— wherever it was— was under control. Bin fires were not uncommon in the 1980s, and when they started they were often handled by the cabin crew without further intervention from the pilots.
There was also an issue with the landing at Cincinnati, which at the time of the Mayday call was not the closest airport. Standiford Field Airport in Louisville, Kentucky was closer, and the NTSB concluded that an earlier landing would have saved lives. First Officer Ouimet testified that landing at Louisville really wasn't a possibility; when the electrical outages began and Captain Cameron lost his flight instruments, he had to literally fight the plane to descend and eventually land. Given these conditions, a landing at Louisville wasn't possible because the airport was too close to descend into safely.
The NTSB eventually released a revised report with altered, though not completely changed, conclusions. They specifically removed the word "delayed" from their findings related to the plane's descent, instead stating the "time taken to evaluate the nature of the fire and to decide to initiate an emergency descent" was a contributing factor to the disaster's outcome. The report remained quite critical of Cameron and didn't absolve him from what the NTSB determined was his role in the tragedy.
Air Canada Flight 797 Legacy
The flight crew received multiple awards for their heroic actions and efforts to save lives. The flight's legacy still impacts much of what we take for granted as fliers today. Flight 797 was responsible for the FAA's recommendation that smoke detectors be installed on all planes, and it contributed to requirements that passengers located in the exit row of aircraft be briefed on how to operate emergency doors if asked by flight crew. It also led to better training and protective equipment for flight crew in the event a fire starts while the plane is in flight. It also led to emergency lighting, which was not standard on aircraft at that time but would likely have helped many people as seen by the location of some of the bodies, which indicated some people were disoriented while searching for an exit.