I just saw the CBC documentary, and was glued to the tube. A fascinating portrayal of professional investigators doing their job.
One thing in particular grabbed me. The comment by the investigators that most people's focus is on the initial event, but it's not their focus. Their focus is what was the actual reason the airplane crashed, and that is rarely the initial event. They specifically mentioned the initial event on flight 111 was likely an electrical short arcing and insulation catching fire, but that isn't what caused the plane to crash. Several wires can short out, arc, and insulation catch fire with no ill effects. The plane continues flying normally.
Instead, what they were looking for is what caused this insulation fire to spread, and how did the spreading fire cause the airplane to become unflyable? If you find that out, and act to prevent it happening again, you not only render small insulation fires inconsequential, but a host of other initial events, some of which haven't happened yet but could, no longer cause catastrophic failure.
Fascinating. An illustraion, to me at least, of how experienced, competent professionals break right through the "fluff" that most of us get caught up in and get straight to the meat of the issue.
The TSB's primary goal is improved future safety. From this perspective, flammable materials are a great concern and their emphasis on this issue is appropriate. The flammability characteristics of metallized mylar was known to the FAA and manufacturers several years before the crash of Swissair 111. Unfortunately, neither the industry nor regulators were quick to act on this problem. To this day, many aircraft are still flying with this insulation material. The Airworthiness Directive (AD) issued by the FAA mandating the remooval of this material gave the carriers five years to replace the insulation. Carriers often fail to act until the deadlie is imminent. And too often they act by requesting more time and whining about the cost. By emphasizing the imprtance of this issue, we can hope that the TSB's report on SR111 will accelerate the replacement process.
Even though the spread of the fire was in some respects more important than its origin, we would have been dissapointed if the origin had remained a complete mystery. Clearly the TSB made a great effort pursuing this information, even though they could have given up much sooner. We believe that the information that was reported in this area will also serve the interests of future safety. There is another sub-plot in this story. The design, construction, testing, certification and installation of the in-flight entertainment system (IFEN) was a disaster in its own right. For details, see Gary Stollers investigative report from USA TODAY. He exposes serious flaws in the FAA's oversight of the process of certification of supplemental equipment for use on commercial aircraft. We believe that the TSB's efforts and report, which establish that the IFEN wiring was involved in the initial (lead) arcing event, will accelerate much needed investigation and reform in this area.
Links to other background information on related issues can be found on the swissair111.org homepage.
"Fascinating. An illustraion, to me at least, of how experienced, competent professionals break right through the "fluff" that most of us get caught up in and get straight to the meat of the issue."
Dayne with all due respect I am pretty assured that the TSB would not consider the IFEN-it's installation or it's certification to be 'fluff' or inconsequential in anyway. Just read the Final Report and see how much of it is devoted to the flaws in that entertainment system. I do understand what you are saying but I will tell you that I'm darn glad (even though it's horrible) that we know where this fire started and that the TSB didn't give up in their quest to find this initial event. Furthermore as Mark states there is plenty of reason to be concerned about the issues surrounding the IFEN. It's certainly not fluff to anyone that lost a family member on that airplane nor should it be to the public who should be protected from anything as outrageous as this ever happening again. The FAA has a lot of questions to answer concerning the IFEN- and so do many other individuals. I personally thought the mylar insulation was a serious enough issue to show up with Lyn Romano (IASA) at the FAA and ask them to speed up the replacement of this volatile material on all aircraft but as I stated in another post our pleas had no effect on their decision to give the airlines 5 yrs. to get this done.
Just wanted to add this link:
In fact check this out from '00 if you can believe it! The FAA then gave the airlines an extra year to replace mylar after we met with them in Washington.
Oh, fiddlesticks, I went and done it again. Twice this time. Sorry about false reply posts.
The whole issue of certification is a complicated one, isn't it? Like I remember one part of the docu showed a reportedly inflammable material burning while stretched across holders in a vertical position. Was the material tested in a horizontal position, and not igniting while horizontal, was mistakenly labelled inflammable?
I can see, myself, something like that happening. Or something like it's wasn't flammable in the lab, but it becomes flammable 5 years later after dust from the galley has gathered on it?
And, of course, the more rigorous and demanding the certification process is, the more time consuming and costly the introduction of new or altered aircraft become. Forcing the nasty decision that we've done as much as we're going to. Even though we're pretty sure there's something, somewhere, that's not right, we're still going to have to quit testing now.
I view it as inevitable that stuff like that's going to happen, and accept that when I fly, there's always a small chance something like that will happen. My hopes are that, if it does, at least my departure would result in a problem being identified and fixed.
Oh, and somewhat off topic, but at my final departure, I ask for just 5 seconds advance warning. I really don't want to leave without being able to utter "Oh, Fiddlesticks!" Or words expressing the same sentiment more forcefully.
Good point BF, I made a poor choice of words. I didn't mean to give the impression that I or anybody else thought the intial fire starting event wasn't important in it's own right. And I apologize for doing so.
I was mostly entranced by being given an insight at how the investigators go about their work. A lot of things I didn't know. And some things that surprised me, like pouring through a warehouse full of big boxes containing recovered parts. And going through these pieces by hand, looking for a single little bracket that might tell them something. No detail too small taken to the max.
Interested sorry I didn't mean to come off so strongly! I understand your point regarding the investigative process.
Part of the FAA's excuse for giving airlines an extra year for replacing Mylar insulation:
"This isn't material which will itself propogate a fire. You have to have an ignition source and the risk of fire aboard an aircraft is very low."
You've got to 'love' the irony that is the FAA. Yeah an ignition source such as a poorly installed, poorly (FAA) certified IFEN. They are so duplicitous it is amazing.
I wonder what would happen if there was a publically available list of airlines and aircraft models that still had MPET covered insulation. If people started taking that into consideration when booking flights the airlines might be more motivated to speed up the process.
Now I know that the Canadian fleet is much smaller than the US airline fleet, but we managed to purge MPET from the whole fleet already. It can be done.
So if you are flying from the US to Canada, and want to be sure to avoid an aircraft with MPET, fly a Canadian airline. And tell the US carrier why you are avoiding them. In writing.
"So if you are flying from the US to Canada, and want to be sure to avoid an aircraft with MPET, fly a Canadian airline. And tell the US carrier why you are avoiding them. In writing."
Kevin, that's good advice but I doubt many people will do that as tragedies like sr111 aren't all that common. It takes an ignition source such as the wiring to the IFEN to cause the mylar to ignite. It's really shocking when you think about it, that airplane manufacturers would use this type of material on their jets. I wonder too if most people are even aware of the problems associated with mylar insulation as the airlines certainly don't warn their passengers of the dangers looming aboard their jets. Just as cigarette manufacturers are responsible for labeling their products with the dangers associated with smoking, the airlines should have to expose all known risks to their passengers so that they can make an educated decision about which airplanes to avoid.
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