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This article appeared in the WSJ in January of 1999 more than a year after the tragic crash of sr111. It caused quite a stir.

By WILLIAM M. CARLEY
Staff Reporter of THE WALL STREET JOURNAL

Aviators around the world have been arguing for months about whether the pilots of Swissair Flight 111 should have flown by the book or by instinct.

Now a summary of the cockpit voice recording shows that the flight's two pilots were sharply at odds over that very issue. The co-pilot wanted to scrap the rules and land quickly. The captain insisted they stick with convention.

Swissair 111 Crash Spurs Debate on Following Cockpit Procedure (Dec. 16)




The issue is important. Critics argue that a prompt landing could have saved the jet, while Swissair officials have contended that such a touchdown wasn't possible.

As smoke seeped into the cockpit of the MD-11 the night of Sept. 2, the pilots could have headed straight for the Halifax, Nova Scotia, airport rather than follow a lengthy checklist and plan other time-consuming procedures, such as dumping fuel. While the cockpit-recording summary doesn't provide any evidence of an acrimonious argument, it does show the Swissair co-pilot repeatedly suggesting steps aimed at a quick landing, and the captain rejecting or ignoring those proposals.

The co-pilot wanted a rapid descent. He suggested dumping fuel early so the jet wouldn't be too heavy to land. And he talked of heading directly to the airport rather than turning out to sea to dump fuel.

But the Swissair captain told the co-pilot, who was flying the plane, not to descend too fast. The captain delayed a decision on dumping fuel. On the issue of heading for the airport or turning toward the sea, the captain, apparently preoccupied with the checklist, didn't give any definitive answer.

At another point, the captain brushed off a proposal by the co-pilot. "The captain said, in effect, 'Don't bother me, I'm going through the checklist,' " one person familiar with the cockpit-recording summary said.

Minutes later, the jet plunged into the Atlantic Ocean, killing all 229 on board. The Canadian government is investigating the crash.

Differences between the captain and his co-pilot during the final minutes of the flight haven't been revealed before because, under Canadian law, the cockpit voice recording can't be released publicly. But a preliminary summary of the recording, prepared by Canadian-government investigators, was obtained by The Wall Street Journal. The summary reveals the rare drama of two pilots battling to save the plane -- and their own lives -- while at odds over how to do it.

David Austin, a spokesman for the Transportation Safety Board of Canada, said he couldn't comment because he was prevented by Canadian law from discussing the contents of the cockpit voice recording. Swissair also declined to comment, saying the voice recording is confidential.

The captain of Flight 111 from New York to Geneva was 49-year-old Urs Zimmermann. He was a veteran Swissair pilot, although he had been flying the MD-11 for just over a year. The co-pilot was Stefan Lowe, 36, who had flown for Swissair since 1990 but had been co-piloting the aircraft for just four months. Conversations between the two, mostly in Swiss German, were described in English in the summary.

The flight began smoothly enough. After the jet took off and climbed to 33,000 feet, the cockpit recording picked up the sounds of cutlery and a conversation about food. The pilots were eating dinner.

But at 10:11 p.m. local time, there was a strange smell. At first the pilots seemed confused about its nature, but within two minutes Capt. Zimmermann said he could "definitely" smell smoke, according to the summary. Though investigators are checking cockpit wiring, the cause of the smoke is still unknown.

The pilots discussed turning back to Boston, New York or Bangor, Maine. But when Co-pilot Lowe radioed the "PAN, PAN, PAN" distress call to a Canadian air-traffic controller, the controller suggested Halifax, nearly dead ahead, only 70 miles away.

At 10:16 p.m., Co-pilot Lowe, who was flying the jet through its autopilot, turned toward Halifax. Just 14 minutes remained before the crash.

"Swissair One Eleven, you're cleared to ten thousand feet ... ," the Canadian controller radioed. But when the co-pilot told Capt. Zimmermann the jet would descend to 10,000, the captain ordered him "not to go too fast," the summary says, apparently meaning "don't descend too fast."

The Swissair pilots, meanwhile, had donned their oxygen masks. Because microphones in the masks picked up their breathing, respiration rates could be measured. Capt. Zimmermann's had soared to nearly 25 breaths per minute, indicating high stress. Co-pilot Lowe's was a more moderate 11 breaths per minute.

There were reasons for stress, beyond the central one. The pilots didn't have landing charts for Halifax at hand, so they had to ask a flight attendant to bring them forward. The chief flight attendant had to be informed about the diversion to Halifax; he announced it to passengers in three languages. And the pilots had to make more radio calls to the controller.

At 10:20 p.m., the controller radioed, "You've got thirty miles to fly to the threshold" of the Halifax runway. By this time, Co-pilot Lowe, who may have been heeding Capt. Zimmermann's admonition, had slowed the jet's rate of descent to 3,100 feet per minute from 4,000 feet per minute.

The co-pilot was clearly worried about that. According to the summary, he told the captain he wanted to descend "as fast as possible" so they could land if the smoke got too dense. The jet was now at 19,800 feet.

Co-pilot Lowe also asked the captain about dumping fuel. The two talked about whether to dump immediately or to wait awhile. Capt. Zimmermann, the summary says, put off making the decision.

The air controller, meanwhile, had guided the jet due north, pointing it slightly to the left of the airport so the plane could cut enough altitude to make a direct approach to Halifax runway 06.

At 10:22 p.m., the crew had to make a crucial decision. Swissair officials contend the jet was too high and heavy with fuel to make a direct approach to runway 06. The jet was 25 miles from the airport and, at 11,900 feet, still too high for a normal approach. But a number of pilots have said it was low enough for a steeper, emergency approach. Should the jet turn right toward the airport or circle left, back out to sea?

As for dumping fuel, in the five minutes or so it would take to fly directly to the airport, the MD-11 could have cut its weight to its maximum overweight-landing limit of 218,000 metric tons from 230,000 tons. But jettisoned fuel might have spattered people and property below.

"Are you able to take a turn back to the south, or do you want to stay closer to the airport?" the controller asked. Co-pilot Lowe asked the captain whether to turn south for dumping or land the plane. But Capt. Zimmermann, the cockpit-recording summary says, didn't give any definite answer.

"OK, we are able for a left or a right turn toward the south to dump," Co-pilot Lowe radioed the controller. As he began circling left to head out to sea, however, he apparently was worried that the jet would get too far from the airport. He would reduce speed if the captain agreed, he told Capt. Zimmermann.

The captain, according to the summary, replied that he was in the midst of a checklist and "didn't want to be interrupted" so often. Do what was appropriate, he told the co-pilot.

A minute later, at 10:23 p.m., the jet's autopilot stopped functioning and Co-pilot Lowe radioed that he had to fly the plane manually. Then, in overlapping transmissions, both Capt. Zimmermann and Co-pilot Lowe radioed that the jet was declaring a full-blown emergency, with the co-pilot adding, "We have to land immediate."

At this point, the summary says, respiration rates of the captain and co-pilot were both at 25 breaths per minute, showing both under high stress. The summary adds that their words became rushed, their voices urgent.

At 10:25 p.m., perhaps because of the thickening smoke, Co-pilot Lowe told the captain it was all he could do just to fly the plane. Seconds later, his instruments -- bright video displays -- went dark, and he spoke of flying on a few standby instruments.

The cockpit voice recording stopped. Five minutes later, Swissair 111 went down.

Updated January 21, 1999 3:57 a.m. EST


http://online.wsj.com/article/0,,SB916877132209838000,00.htm

I was shocked to find that the above link still works.

Said one member of the sr111 board:

“the deeper one digs, the more horrified we will become.”

Said another poster who was formerly an Eastern Airline pilot (for 20+ yrs.) and now investigates aviation accidents ((ISASI which stands for International Society of Air Safety Investigators) and lives in the Miami area (and posted by his real name complete with credentials)

" Fantastic work. That article you posted
is very very interesting. It goes with what I have
been saying all along. These passengers deserved
better. In the end what they got was a timid, poorly
coordininated crew." That is relatively clear, even
from a third hand summary. The captain's respiration
rate showed that he was overstressed some time before
the co-pilot, and when the co-pilot deferred as
he should to the captain, the captain shed the
task. Sometime the best game player comes to pieces
when he is *actually* at risk. You can fly these
profiles in the simulator forever, but until you try them
*for real* there is no telling how an individual is
going to perform. Zimmerman does not seem to have
performed very well.”

Vic Gerden’s remarks concerning this article:

Remarks as delivered by Vic Gerden to a News
Briefing at Shearwater, Nova Scotia, 22 January
1999

“The media has generally been responsible and
circumspect in attempting to keep the public informed and in
trying to get it right. Unfortunately at times you are
all faced with a considerable amount of
misinformation from various sources, other than the TSB
investigation. Some sources, in their attempt to analyze and draw
conclusions from their appreciation of the facts or issues,
sometimes present misleading interpretations or
inadvertently introduce mis-information. When I release
information during this investigation I must do my best to
ensure that information is accurate, based on fact, and
it must be fair to all concerned. For some issues
involving judgments, analysis and final conclusions, the
TSBC process requires that a full fairness process
that involves the Parties with Direct Interest (PDIs)
being given an opportunity to review the findings and
provide their input for Board consideration. The Board
members then must decide on and approve the final
conclusions of the investigations. When uninformed
speculation gets widely promulgated, it is unfair to the
next-of-kin of the victims and can at times be prejudicial to
the investigation. And it sometimes means the
investigation team has to expend considerable effort in trying
to correct and clarify the information. To
give you an example of this, we have just finished
examining the available components of the copilots seat.
This examination has revealed damage to the seat belt
that is consistent with the co- pilot seat being
occupied when the aircraft struck the water. You probably
remember the number of times that speculative stories
appeared about the crew abandoning the cockpit.** That type
of speculation can cause undue hardship to the
families of the crew and the victims families. This is
just one example of misleading and inaccurate
information that can be damaging and does not further the
advancement of safety.

I must add here we have only recovered a small
portion of the captain's seat and are unable to make any
determinations about that seat. Of course, we are continuing our
attempts to find and reconstruct that seat. I can
also say today that the conclusions and
interpretations, as reported fairly widely in the last day or so,
concerning what went on in the cockpit of the aircraft, are
misleading and not accurate. As you know, I cannot
comment on or divulge the actual conversations recorded
on the Cockpit Voice Recorder - that is prevented by
Canadian law. But, I can say that the characterizations
and the interpretations in the media of that
conversation and events are misleading. Some of the facts
concerning times and ATC conversations and events are
accurate and you should know that the transcripts of the
ATC tapes are available on the TSB web site. But, the
interpretations of the interactions between the crew members are
not only misleading and inaccurate, but are
unfair. Early on in the investigation the investigation team
attempted to derive as much factual information as was
possible from various sources. We did not have the
aircraft wreckage at this point, but we did have the Air
Traffic Control Services tape, Radar tape, and Flight
recorders. You'll remember me saying it would take
some time to recover this aircraft from 200 feet below
the ocean. When analyzing that information, care was
taken to avoid any premature conclusions in the
preparation of documents for the investigation team.
We have a very large International team of
investigators here. We do need to share information and that
type of document is produced as a composite and
intended to contain just factual information as best we
knew it at the time. That document has of course been
updated and changed as the investigation proceeds. We
improve our information as we get it from various
sources. Whether or not some of the information
currently being circulated came from such a document is not
something I will pursue further, but I will say that there
is much more additional information that we had to
deal with and consider as time has
progressed. At any rate if you receive information concerning
this investigation, and it has not been released by
the TSB it may be speculative and unconfirmed.
Now, I understand there is significant thirst for
information about this accident around the world. It is my
intention to provide periodic updates as factual
information becomes available. That information will also be
placed on the TSB web site at: http://www.bst-tsb.gc.ca.
http://www.bst-tsb.gc.ca. “

** It was later reported that Zimmermann's seat was in the 'back-and-out" position although this does not in anyway prove that he bolted from the cockpit.

Mark points out the obvious:

“Mr. Gerden's remarks suggest that the
characterization of interactions among the flight crew are unfair
and inaccurate. He does not say that the facts are
inaccurate. Nor does he provide information to correct these
supposed inaccuracies. If his suggestion is that there is
more information to be considered before we lay blame,
of course I'm sure he is right. But we are not so
naive as to suppose that the flight crew's behavior was
the only factor in the accident. I, for one, would
like to have the facts so I can draw my own judgment.
It is unfortunate that Canadian law is at odds with
this interest.”

Swissair Report Criticized

HALIFAX, Nova Scotia
(AP) - The chief Canadian crash investigator
Friday criticized as inaccurate a report that the two pilots of
Swissair Flight 111 disagreed over emergency procedures
minutes before the plane crashed last year. Vic
Gerden, who heads the Transportation Safety Board of
Canada investigation of the Sept. 2 crash, said the
report in Thursday's Wall Street Journal
made interpretations of cockpit voice recordings ``that are not only
misleading but inaccurate and unfair.''Flight
111, en route from New York to Geneva, crashed off
Nova Scotia after the pilots reported smoke in the
cockpit. All 229 people on board were killed. The
Wall Street Journal reported that co-pilot Stephen
Loew, who was flying the MD-11 at the time, wanted
to ignore the rules and land swiftly after
the smoke appeared. The report said the captain, Urs
Zimmermann, insisted on following standard - and slower -
procedures for dumping fuel before an emergency
landing. The newspaper said it based its information on a
preliminary summary of the cockpit voice recording.
Canadian law prohibits the public disclosure of cockpit
voice recordings. Gerden said the newspaper
story mixed accurate information concerning
timing and air-traffic control conversations with
speculative interpretations. ``There is a tendency to
try to solve the accident without all of the
facts,'' Gerden told a news conference in Halifax. In
Switzerland, Swissair's chief MD-11 pilot, said that to the
best of his knowledge the Flight 111 pilots behaved
``absolutely quickly and professionally.'' ``

David Austin, a spokesman for the Transportation
Safety Board of Canada, would not confirm or deny the
Journal report. He pointed out, however, that both pilots
are held accountable when the co-pilot is flying. Swissair declined comment.

On Monday, January 25th, 1999 I called the WSJ and they confirmed that the information reported in their controversial article was correct. Furthermore they insisted that I speak with the reporter, WILLIAM M. CARLEY who broke the story, and he also confirmed the accuracy of his account. He said he had been able to obtain a copy of the preliminary summary of the recording, prepared by Canadian-government investigators and had characterized the exchange between the two pilots accurately. (My comment)

From the former Eastern Airline Captain:

"Being the aircraft left JFK well under
it's maximum takeoff weight, which only makes sense,
no air carrier is going to tanker un-needed fuel,
wasn't F/O Lowe correct?" Yes! Emphatically! It
is my opinion that the aircraft should be placed on
the ground at *ANY* sign of fire. And I thought the
industry learned that with the DC-9 fire at Cincinnati
some years ago. Sorry, guys, I don't remember the
carrier or the year, and I am not even sure it was a 9.
But I am talking about the incident where the crew
tried to fight a cabin fire and damned near lost the
airplane. As to the overweight issue, I had an old Dane for a
professor at the Naval Postgraduate School whose favorite
saying was: "It is better to hit the far fence at taxi
speed than the near fence at flying speed." Even
landing grossly overweight, the aircraft can be slowed to
a managable speed before departing a reasonably
adequate runway which Halifax is. And I agree with
Wolk about the numbers. The aircraft could have been
descended and put on the ground much more rapidly than it
was. I do not consider it Monday morning
quarterbacking when I say that it should have, in the presence
of a known fire.”

A poster from the sr111 board:

“Someone just sent me this
article: Swiss Air/Legal Hassles
“The
Canadian investigation team looking into the crash of
Swiss Air Flight 1-11 is locked in a legal battle over
the cockpit tapes. Lawyers in the US have launched
more than two dozen lawsuits against Swiss Air to get
the tapes released. The Canadian Transportation
Safety Board is insisting the recording must remain
confidential to protect the privacy rights of the crew. All
229 people on board the flight died when it slammed
into the Atlantic Ocean off the coast of Nova Scotia
last fall.” So, there is
hope after all. Maybe one of these cases will succeed,
and we will finally have some concrete
information. The article is at http://www.cadvision.com/

It never happened. The cockpit tapes were not obtained by anyone outside the investigation to the best of my knowledge and we never got a real answer to our concerns regarding the pilots’ actions. (My comment)

From the newswires:

New Evidence Reveals That Aviation Lawyer, Arthur
Alan Wolk, Correctly Identified Cause of Swissair 111
Within 24 Hours of the Crash PHILADELPHIA,
Jan. 22 /PRNewswire/ -- According to Philadelphia
aviation attorney, Arthur Alan Wolk, analysis of the
cockpit voice recorder of Swissair 111 reveals a
disagreement between the captain and first officer on the
appropriate procedures to be followed when smoke began
filling the cockpit. The first officer
recommended that the aircraft be landed immediately, and the
captain declined that recommendation. That decision was
fatal to the crew and all the passengers aboard.
Fire in an aircraft cabin is one of the most serious
emergencies that can affect an aircraft in-flight. An
emergency descent and landing is the only procedure that
can save the aircraft. There was nothing to prevent
Swissair 111 from making a safe landing within minutes of
the first discovery of smoke, and nothing would have
presented any danger to the passengers or crew by landing
slightly overweight on a runway that was more than ample.
It is sad that so many lost their lives, but
hopefully this will remove any doubt from any airline and
from any flight crew that smoke in an aircraft is not
a time for a majority vote; it's the time for the
fastest possible emergency landing at the nearest
airport, regardless of the circumstances. Although
immediately following the crash Swissair denied that such a
landing was possible, analysis of procedures in the MD-11
flight manual reveal that such a landing at Halifax
could have been safely made within seven minutes of the
discovery of smoke -- about half the time the aircraft
remained airborne after that discovery. Other
parts of the investigation may reveal that electronic
engine controls need to be isolated from electrical
faults so that loss of engine power does not complicate
the emergency landing process. There is much more to
be learned from the investigation of this crash, but
one thing is certain -- there is neither adequate
means nor training currently available to fight a fire
in an aircraft in-flight, in spite of the well-worn
but true statement "where there's smoke there's
fire." For more information about Swissair
Flight 111, call Arthur Alan Wolk, Esq. at 215-545-4220
or visit his web site at http://www.airlaw.com

A Letter in the Canadian News:

Thursday, January 28, 1999 Transport
board whiners

To the editor: Somebody tell the
Transportation Safety Board to stop whining. While transcripts
of cockpit-voice recordings are confidential in
Canada, they're not in the United States. There were a
lot more Americans on Swissair Flight 111 than
Canadians, and down here we would like to know what
transpired onboard. The Wall Street Journal's printing of
these transcripts is in no way detrimental to the TSB
investigation, since our own NTSB routinely releases them during
their investigations with no apparent
harm. Everything about that investigation is subject to public
scrutiny down here, and it's all going to leak sooner or
later, so they might as well get used to it. J.
Elliott Jacksonville, Fla.Via the Internet

Captain Ken Adams assisted the CTSB in the investigation of sr111 is what I was told. He also participated in an interview with the CBC in the Fall of ’99:

“Ken Adams is an MD-11 Pilot for Delta airlines. He confirms that Swissair was wrong about the aircraft's inability to land immediately.
"Physically it is possible to get the airplane on the ground in less time," he says. "I mean you could do that with a lot of different techniques, you can get the airplane down and on the ground probably fairly quickly but that's what the hindsight, in that I only have 10 minutes or 12 minutes to put the plane on the ground… …and I think that if you look at the Swissair accident I think it was very insidious at first it wasn't a lot of smoke, there wasn't a lot of other little problems going on and so you know these guys were dealing with a lot of different problem and were trying to figure out where is it coming from, what's causing this, and that's time and unfortunately that's time they didn't have."
Swissair corporate executives refused to be interviewed for this documentary, but one year after the crash they issued this statement announcing a change in their procedures after discussions with the manufacturer… "It was decided that the so-called emergency descent procedure is the best procedure for quickly bringing an aircraft into a position to make an emergency landing."

http://cbc.ca/national/magazine/swissair/
 
Posts: 2580 | Location: USA | Registered: Sun April 07 2002Reply With QuoteReport This Post
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Here is some additional information...

******************************

THE KITCHENER-WATERLOO RECORD
11/20/2002

Air traffic transcript ban unconstitutional, court told

The Information Commission says a law that prohibits the public release of air traffic control transcripts or recordings is unconstitutional and has asked the Federal Court to strike it down.

It's the first time that the commissioner's office has filed a suit using a constitutional claim to force the release of information, said Daniel Brunet, general counsel for Information Commissioner John Reid.

The suit is aimed at forcing the Transportation Safety Board of Canada to release air traffic control transcripts and recordings sought by journalists under the Freedom of Information Act.

******************************

I presume that the article above relates to the links below:

Office of the Information Commissioner of Canada - Status of Air Traffic Control Communications

Office of the Information Commissioner of Canada - SR111 ATS audio recordings

Federal Court of Canada Disposition - 2001

TSBC - Annual Report 2001-2002 relating to Access to Information Act and Privacy Act
 
Posts: 142 | Location: Ottawa, Ontario, Canada | Registered: Mon April 08 2002Reply With QuoteReport This Post
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I hope that this attempt will fail. In my view, there is absolutely no reason nor value, other than commercial, in the release of actual audio tapes. Any information for press purposes can be obtained thru the written transcripts which are released. It is this type of activity which is prompting the fight over cockpit video.
 
Posts: 58 | Location: USA | Registered: Sun April 07 2002Reply With QuoteReport This Post
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CD Thanks for the extremely interesting information. I had no idea that was going on as I don't recall the press ever reporting it. Very interesting.

Barbara
 
Posts: 2580 | Location: USA | Registered: Sun April 07 2002Reply With QuoteReport This Post
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Cecil, I don't think I could possibly listen to those tapes, speaking for myself and I doubt that Mark could either. I do wish though that we would be told more directly if the WSJ's version of the tragic events was accurate. Considering the horrible outcome, I think it's quite believable. I think this investigation has not been nearly open enough to the public in general. I can't even imagine why the TSB would not allow the family members of sr111 to see a copy of their draft results. I think that is just awful. We have every right to know what happened to our loved ones. I think it's outrageous the way information has been withheld. Openness during an investigation helps to keep it honest IMO. There is an arrogance about this that blows my mind.
 
Posts: 2580 | Location: USA | Registered: Sun April 07 2002Reply With QuoteReport This Post
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Barbara... I would think that the WSJ report is probably most accurate. When this report was released, I was outraged with what I read, and as well as I recall, expressed same on one of the boards I was participating in at the time. My opinions were based more on SR proceedures rather than individual actions. In my opinion, it was those proceedures which created the foundation for the crew mindset and cockpit activities that followed.

I think that you are correct, the IFEN caused the fire. By itself, it did not cause the accident.
 
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Sorry, please correct the following to read:

I think that you are correct, the IFEN caused the fire. By itself, in my opinion, it did not cause the accident
 
Posts: 58 | Location: USA | Registered: Sun April 07 2002Reply With QuoteReport This Post
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Cecil, I agree with you completely on all of your statements. The tragedy was clearly caused by a chain of events where as far as I can tell, everything went wrong. I also agree with you regarding swissair's procedures which were clearly flawed. If they weren't they wouldn't have shortened the emergency checklist following the tragedy.
 
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I just wanted to add, that there is no denying that the investigation of the swissair tragedy has exposed many flaws existent in the MD-11 aircraft that contributed to the outcome as well as human factor issues. Just one glaring example of that is the mylar insulation used which the CTSB investigators have said clearly conducted the fire aboard sr111. For more information on this and other discoveries made by the CTSB regarding this tragedy:

http://www.bst.gc.ca/en/index.asp
 
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I was always amazed that this near tragedy experienced by swissair in '93 didn't seem to have an impact on their procedures and general philosophy:

http://www.aviationsafetyonline.com/_books/sr111_chapter_4_engl.html
 
Posts: 2580 | Location: USA | Registered: Sun April 07 2002Reply With QuoteReport This Post
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Here is an interesting article from a past issue of Air Safety Week:

Land immediately. The Nationair crash mentioned above was one of the inflight fire tragedies prefigured in a 1986 article written by noted aviation safety expert Gerard Bruggink. Readers will recall that at last week's CASS '99 conference, speaker C.O. Miller pointedly suggested that Bruggink's paper should be required reading for those investigating the crash of Swissair Flight 111 (see ASW, May 17). We contacted Bruggink, who provided a complete copy of his paper, which appeared in the Dec. 1983 edition of a now out-of-print publication, The International Journal of Aviation Safety. Bruggink said the article's salient points remain relevant. An uncontrollable cabin fire constitutes a dire emergency in which the crew should proceed on worst-case assumptions for two reasons: 1. The uncertainty about the time and manner in which a continuing and uncontrollable fire may affect flight control systems or breach fuel and hydraulic lines (we might add, "breach oxygen lines" as well).

2. The unpredictable manner in which smoke may make conditions in the cabin intolerable and incapacitate occupants before the cockpit is seriously affected.

His advice: "Get the damn thing on the ground." His trenchant paper indicates that in most cases, the time between the initial discovery of smoke/fire and emergency landing or crash was on the order of 8-10 minutes. Bruggink, tel. 334/774-3443

The Uncontrollable Cabin Fire: Land and Evacuate

Key points:

Although cabin fires constitute less than 20% of all inflight fires, they claim an inordinate number of lives.
The larger the aircraft the more difficult it is for the flight crew to assess the seriousness of prevailing circumstances.
When an inaccessible fire does not respond immediately to built-in suppression systems, the situation should be treated as an emergency of the first order.
Once the decision is made to make an emergency descent, the workload makes it essential to keep the cockpit crew intact, especially a two-man crew. Dispatching a crew member into a cabin at a later stage brings the additional risk of his inability to return to the cockpit for reasons such as the uncontrollable movement of passengers or an extreme aircraft attitude.
Smoke evacuation procedures can provide temporary relief but they may also aggravate the fire...
VFR conditions during at least the final part of the descent may provide the captain with an alternative when the criticality of conditions...warrant it: the decision to make a controlled crash landing instead of delaying the evacuation process by continuing towards a distant airport.
(The crew) must be mentally prepared for the moment the CRT (cathode ray tube) runs out of advice with its final message: "Land as soon as possible."

Source: The Uncontrollable Cabin Fire, by Gerard M. Bruggink
 
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quote:
Originally posted by BF:
[qb]..."Get the damn thing on the ground." His trenchant paper indicates that in most cases, the time between the initial discovery of smoke/fire and emergency landing or crash was on the order of 8-10 minutes...[/qb]
As the ASW article indicates the Bruggink had his article published in December of 1983, I would suspect that it was prompted by the following accident:

On June 2, 1983, Air Canada Flight 797, a McDonnell Douglas DC-9-32, of Canadian Registry C-FTLU, was a regularly scheduled international passenger flight from Dallas, Texas, to Montreal, Quebec, Canada, with an en route stop at Toronto, Ontario, Canada. The flight left Dallas with 5 crewmembers and 41 passengers on board.

About 1903, eastern daylight time, while en route at flight level 330 (about 33,000 feet m.s.l.), the cabin crew discovered a fire in the aft lavatory. After contacting air traffic control (ATC) and declaring an emergency, the crew made an emergency descent, and ATC vectored Flight 797 to the Greater Cincinnati International Airport, Covington, Kentucky.

At 1920:09, eastern daylight time, Flight 797 landed on runway 27L at the Greater Cincinnati International Airport. As the pilot stopped the airplane, the airport fire department, which had been alerted by the tower of the fire on board the incoming plane, was in place and began firefighting operations. Also, as soon as the airplane stopped, the flight attendants and passengers opened the left and right forward doors, the left forward overwing exit, and the forward and aft right overwing exits. About 60 to 90 seconds after the exits were opened, a flash fire enveloped the airplane interior. While 18 passengers and 3 flight attendants exited through the forward doors and slides and the three overwing exits to evacuate the airplane, the captain and first officer exited through their respective cockpit sliding windows. However, 23 passengers were not able to get out of the plane and died in the fire. The airplane was destroyed.


Aircraft Accident Report - Air Canada 797 - Cincinnati - June 2, 1983
 
Posts: 142 | Location: Ottawa, Ontario, Canada | Registered: Mon April 08 2002Reply With QuoteReport This Post
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Chris that makes sense that this very well could be exactly the tragedy that he is referring to in that paper. This should have been a huge wake-up call to any pilot facing smoke of unknown origin not to mention the resetting of circuit breakers (multiple times). A perfect example of how unpredictable hidden smoke/fire situations can be and how quickly they can escalate into an uncontrollable disaster. Thanks for posting that.
 
Posts: 2580 | Location: USA | Registered: Sun April 07 2002Reply With QuoteReport This Post
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Barbara... I have previously mentioned the AC incident at CVG time and again on various boards.
At the time, it became one of the leading examples we used during training on handling in-flight fires, and remained so at the time I discontinued flying. Prior to the Air Canada accident, there were two other accidents were used to illustrate the problems associated with in-flight cabin fires. In all cases, similarities overlapped.

One, in 1973, a Varig 707 operating RIO ORY had a fire breakout in a rear Lav. At the time, the
airplane was descending and preparing to land at ORY. It only took 5 minutes for the smoke to
become so thick that the crew could not make the airport, and elected to put the airplane down
less that 5 miles from the runway. They did a good job getting the airplane on the ground. The
impact was survival, but only 10 (all crew) who exited the airplane via the cockpit survived.

The second in 1973 involved a Pan Am 707 freighter that just departed JFK for a transatlantic flight. A fire broke out in the cargo and the smoke immediately became so thick that the crew could not see the instruments. They were close to BOS, declared an emergency, and were attempting to land, but were overcome by the smoke. They were not successful.

Thus two accidents in a short time underlined the dire importance of why getting the airplane on
the ground was so important, and must take precedent over all else. Our training, dating back to 1973, was quite clear on policy and procedural content. Each recurrent training session reinforced the importance about initiating proper action with in-flight fires.

Then, along came AC 10 years later. It became the text book example of our curriculum. I guess
anyone can say hindsight is always 20 20, but one only has to examine the circumstances, and
unfortunately, similarities and parallels will be seen with all of these examples, including SR111.
 
Posts: 58 | Location: USA | Registered: Sun April 07 2002Reply With QuoteReport This Post
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"Thus two accidents in a short time underlined the dire importance of why getting the airplane on
the ground was so important, and must take precedent over all else. Our training, dating back to 1973, was quite clear on policy and procedural content. Each recurrent training session reinforced the importance about initiating proper action with in-flight fires.

Then, along came AC 10 years later. It became the text book example of our curriculum. I guess
anyone can say hindsight is always 20 20, but one only has to examine the circumstances, and
unfortunately, similarities and parallels will be seen with all of these examples, including SR111."

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Cecil, It completely baffles me that after all these terrible tragedies occurred, that a crew would do anything but land a plane ASAP. The captain of sr111 has been accused of going by the book, but I can't imagine that the general philosophy of any airline would be anything but to land immediately when a condition such as smoke of unknown origin, or a smell for that matter is detected. There were plenty of precedents even at swissair itself (see Munich '93 near disaster in this thread) that would stand as an example of just why a crew should take any hint of potential fire very seriously. I'm just shocked (even over 4 yrs. later) that an airline would instruct their pilots otherwise or so it would seem. They had at least 20 minutes to bring the plane down as opposed to 8 mentioned in the article.

All you have said is exactly what I would have expected a crew to do. Smoke/odor/fire of unknown origin at 30,000 ft. in the air, is something to be taken very seriously.
 
Posts: 2580 | Location: USA | Registered: Sun April 07 2002Reply With QuoteReport This Post
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December 5, 2000 WSJ

Probe Into Crash of Swissair Flight
111 Prompts Call for Less Trouble-Shooting By STEPHEN
POWER and ANDY PASZTOR Staff Reporters of THE WALL
STREET JOURNAL

Canadian regulators
investigating the 1998 crash of Swissair Flight 111 recommended
in a preliminary report that pilots who detect smoke
or fire should prepare to land immediately, even as
they continue to trouble-shoot the problem in the
air. The Canadian Transportation Safety Board, probing the
crash of the MD-11 that killed 229 people, said
government and industry standards for determining how
quickly pilots should prepare for emergency landings in
such circumstances contained "deficiencies" and urged
the creation of new ones. The move marks the
first time a major aviation regulatory body has
questioned the longstanding practice among airline pilots to
trouble-shoot in the air before making emergency landings.
Airlines and pilots claim it is often premature to declare
an emergency until the extent of a problem can be
determined. "We're not saying 'don't try to identify the source' "
of a fire, said Vic Gerden, the Canadian safety
board's lead investigator, adding, "But a high priority
needs to be given to preparing the plane to
land." The agency didn't issue detailed findings about what
caused the Swissair accident, but the debate over how
quickly pilots should divert to an airport has become a
major point of contention in its aftermath. Some
independent safety experts argue that the Swissair pilots
spent too much time going through a checklist to try to
isolate the source of an ignition rather than making an
emergency landing. The jet, bound for Geneva from
New York, crashed off the coast of Nova Scotia after
pilots reported smoke in the cockpit. Rather than
heading directly to the Halifax airport, the crew
performed several time-consuming procedures, including a
course change out to sea to dump fuel, so the jet
wouldn't be too heavy to land. Swissair, a unit of
SAirGroup, has maintained that since the crew had no way to
know how serious the fire was, its actions were
prudent. But following the crash, Swissair amended its
standards to call for landing at the nearest airport in
case of smoke or fumes "of an unknown
origin." The question of how long airline pilots should
trouble-shoot in the air also is expected to come up when the
National Transportation Safety Board holds hearings this
month on the crash in January of a McDonnell Douglas
MD-80 series jet flown by Alaska Air Group Inc.'s
Alaska Airlines that killed all 88 people aboard. Prior
to that accident off the California coast, the
pilots spent critical minutes analyzing a malfunctioning
horizontal stabilizer. Canadian investigators also
urged installation of fire-detection sensors inside
electronics compartments and in other portions of jetliners
that they said "are seldom inspected." Swissair
already is testing such sensors on some of its
MD-11s. Spokesmen for the U.S. Federal Aviation Administration and
the NTSB said their agencies were reviewing the
Canadian report and had no comment. Russ Young, a
spokesman for Boeing Co., which took over responsibility
for the MD-11 when it purchased McDonnell Douglas
Corp. several years ago, said the company was
"encouraged" that Canadian investigators are "taking such a
comprehensive approach" that includes looking at training and
procedures.

Write to Stephen Power at stephen.power@wsj.com and
Andy Pasztor at andy.pasztor@wsj.com
 
Posts: 2580 | Location: USA | Registered: Sun April 07 2002Reply With QuoteReport This Post
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Here was a comment on the old sr111 board that might interest you regarding swissair (now bankrupt). It was posted as a response to the 1993 Munich incident (I had just posted an article about it) where swissair almost lost another plane to an onboard fire. My recollection is that the poster got this information from a swissair pilot:

"Swissair have been using a training video made of
the 1993 SR551 near-accident as a flight and cabin
crew LOFT training aid for many years. It's now been
withdrawn and isn't "available". The last person to see it
reports that the interview with the SR551 crew that had
been at the end of that tape ... wasn't there any more
when he last saw it.
It's a pity that it isn't any
longer "available" because it could either pose or
answer some difficult questions."
 
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A member of the sr111 board posted the following information that he claimed came off of the old swissair website. It explains a little about what swissair did to change it's checklist procedures in light of the sr111 crash.

In view of the extent and
complexity of its investigation, Canada's Transportation
Safety Board has not yet been able to reach any concrete
conclusions as to what may have caused the fire in the upper
cockpit area. This also explains why so few concrete
actions have been taken to date. The US Federal Aviation
Administration (FAA) has issued three Airworthiness Directives
for all MD-11 aircraft in the last eleven months. The
first directive, issued on November 12, 1998, required
the checking of all cockpit dimmer switches. The
second, issued on December 9, 1998, called for the
checking of all wiring above the forward aircraft door;
and the third, issued on January 28, 1999, required a
general inspection of all electrical wiring and
insulation blankets on all MD-11s. Swissair carried out all
these FAA directives on all its MD-11s well within the
timeframe specified.
On its own initiative, and based
on its own studies and investigations, Swissair has
taken the first concrete action of its own: as a
precautionary measure, the inflight entertainment system has
been deactivated on all its MD-11 and Boeing 747
aircraft. Swissair has also modified some of its flight
procedures for its cockpit crews. In close collaboration
with the manufacturers, Swissair's Operations
department has decided to restrict the "circuit breaker
reset" procedure throughout its aircraft fleet: circuit
breakers that are tripped during flight will no longer be
reset and the circuit will be regarded as unavailable
for the rest of the flight.
The flight procedures
and checklists for "smoke/fire of unknown origin"
have also been closely studied and discussed in
collaboration with the manufacturers. These deliberations
revealed that an emergency descent is the best procedure
for bringing an aircraft quickly into a position to
make an emergency landing.
It must be noted,
however, that only a very limited number of rigid
procedures can ever be prescribed for emergency situations,
since the circumstances and conditions can change
extremely fast. Generally speaking, preparations for
landing will only be initiated at around 3000 metres
altitude during an emergency descent. To keep as many
options open as possible, Swissair has now modified this
procedure to permit emergency descents to continue below
this altitude, if warranted by the situation. This
change is also valid throughout the Swissair fleet.
 
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Here is something to think about. I noticed on the old sr111 board people would often mention that the captain didn't understand the seriousness of the escalating situation onboard sr111. Well if the WSJ report is accurate, why is it that the co-pilot seemed to think the situation was more urgent than the captain? Just another one of those rhetorical questions that will never be answered.
 
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