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CBC Fifth Estate owes SR111 families an apology
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I would like to comment on the CBC Fifth Estate September 16, 2011 broadcast of ‘Swissair 111, the Untold Story”.

I’m an independent researcher that has spent many years looking into the crash of Swissair Flight 111. Outside of the Transportation Safety Board of Canada, and other investigating groups, I guess I know as much about this crash as anyone.

My research was so thorough, that I was even able to identify the installers of the In-Flight Entertainment system on SR111 (members of the ‘overhead’ and ‘floor’ groups), and those that fed the entertainment system cables into the cockpit, and connected its power cables to the breaker panels, starting on September 3rd, 1997.

Over the years, I’ve come to appreciate the detailed forensic work of the Transportation Safety Board of Canada in its investigation, as well as the results of the final report.

The TSB’s main focus was on the thermal-acoustical ‘insulating blankets’ installed in behind the walls and ceiling, which reduces external noise, and helps to control the temperature in the passenger cabin. More specifically, their focus was on the outer film that covers those insulating blankets, called Metallized PET (Polyester Ethylene Terephthalate). It has the undesired property of propagating fire. In other words, it’s not fire-proof, as one would expect it to be. The FAA had been looking at the combustible insulation blankets for several years before to the crash, in response to some incidents of fires in airplanes between 1993 and 1995.

After the crash of the Swissair MD-11, the FAA conducted more extensive tests. They found that Metalized PET easily ignited from simulated electrical arcing at both 115 and 208 volts. The fire, and the heat produced by those tests was significant. Certainly enough to melt the insulation off of adjacent wires, and cause additional electrical faults and short circuits.

My interest on the other hand, has always been on what was behind the ‘initiating’ event of the crash, namely the In-Flight Entertainment system (also known as the In-Flight Entertainment Network (IFEN).

Starting with its bloated, prototype design; ‘contracted-out’ FAA certification; inadequate testing; rushed installations by non-Swissair personnel whose qualifications were never questioned; poor system reliability (the system suffered from multiple component failures, including the IFEN power supplies); overheating of the small metal electrical boxes that were mounted underneath each passenger seat, containing disk drives; and that the Aircraft Flight Manual (AFM) did not properly reflect the integration of the IFEN to the airplane’s power system.

Add to this the fact that the designers – generally inexperienced with the electrical system of the MD-11 - performed an electrical load analysis, and determined that the In-Flight Entertainment system was too power-hungry to be connected to an electrical bus that was specifically intended for ‘accessory’ equipment. The entertainment system was instead connected to an ‘essential’ electrical bus (reserved for essential equipment, including the pilot’s flight displays and instruments).

In addition, the entertainment system had no ‘OFF’ switch, even though the Swissair specifications called for one.

Flight crews were informed via technical bulletin from Swissair that if they experienced problems with the entertainment system, that they should pull a circuit breaker on the avionics panel to kill the power to the whole IFEN. (Imagine controlling your living room lights from the house circuit breaker panel). Some flight crews were even doing this, when they had to ‘reboot’ the entertainment system if it became unresponsive, or to simply cool the cabin because the 2,000 pounds of electronics generated too much heat, and passengers were complaining.

Then there was the issue of mixing wire-types during installation. This is where abrasion of electrical wires can take place due to differences in hardness of the outer insulation. Wires that have significantly different insulation hardness are supposed be routed in separate bundles in order to prevent rubbing together and chafing.

The general purpose wires of the MD-11 included ‘Kapton’ wiring (which has a thin insulation layer for weight savings, but is hard and abrasive), whereas the entertainment system used Tefzel wires (which has thicker, softer insulation).

Experts claim that mixing wire types is a fatal practice. Kapton can wear away softer insulations like sandpaper. In addition, Kapton has unique properties that can result in a phenomenon called ‘arc-tracking’, whereby if the outer insulation becomes charred, then it can become an alternate path for the electricity, instead of the wire’s center conductor. This produces a explosive, high temperature arcing event. (Think of a high-speed gunpowder fuse). And in some cases, the circuit breakers that the Kapton wire is connected to, don’t even trip.

In January 2000, Swissair appointed a special task force after the crash to look into the issues that played a role in the loss of control of Flight 111. In an internal memorandum, officials said that, ” Wire separation, routing, and protection have been proven to be insufficient, especially in the cockpit area. In the case of SR111, this has contributed to the loss of flight essential functions, including display functions."

All of the above items and deficiencies added up to a perfect storm.

At about 10:11 pm on September 2nd 1998, and one hour into a flight between New York and Geneva, the flight crew of Swissair Flight 111 detected smoke in the cockpit. At first the pilots weren’t sure, but within two minutes, Captain Zimmermann said he could "definitely" smell smoke. The flight crew then declared 'Pan-Pan-Pan', which is a condition of urgency, put on oxygen masks, and arranged with Air Traffic Control to divert to Halifax, Nova Scotia.

For the next 20 minutes, Swissair 111 flew in a large descending circle over the ocean in preparation to dump fuel. While the co-pilot flew the airplane, the Captain went through an emergency checklist in the Aircraft Flight Manual used in situations when there is 'Smoke of Unknown Origin'.

In the MD-11 airplane there are three main electrical 'busses', each one powered by its own engine. The busses are all tied together in normal operation, so that if any one or two engines fail, essential systems, like avionics, will still get power from the remaining one. The busses are identified as 'Left', 'Center', and 'Right', which also corresponds to the airplane’s engine positions (On the MD-11, there’s one engine under each wing, and the third engine is mounted on the tail). The electrical busses can be individually disconnected, or turned off, by manually rotating a 3-position 'SEAS' (Smoke-Elec/Air Switch) located on the electrical control panel, just above the co-pilot. The emergency checklist instructed the pilot to change the setting of the SEAS switch in order to turn off the power on one bus, while leaving the other two on. After a brief wait to determine if smoke was still present, the pilot was expected to rotate the switch again, which would re-energize the first bus, and then deactivate another. The object is to isolate, then identify which bus has an electrical problem.

Since the Aircraft Flight Manual didn’t address emergency procedures pertaining to the In-Flight Entertainment system, or identify that it was connected to an ‘essential’ bus, it’s possible that operation of the SEAS switch led to unintentional re-energizing of power to the faulty circuits, making the situation worse.

The fire had originated above the ceiling panels, just behind the bulkhead wall that separates the cockpit from the passenger cabin. This was in an area known to have contained main cable feeds of the In-Flight Entertainment system.

As the fire grew, it continued to move forwards, into the cockpit area. It was in the worst possible place, where the electrical busses converge into a single crippling point on the airplane.

At 10:24 pm the autopilot disconnected, followed by rapidly deteriorating electrical systems over the next 90 seconds. This resulted in the loss of their essential avionics (including the primary flight displays), as well as the last 6 1/2 minutes of Flight Data Recorder (FDR) and Cockpit Voice Recorder (CVR) data.

The flight crew then either lost visual reference to the horizon, or were incapacitated by the smoke and fire.

At 10:31 pm the airplane crashed into the ocean, nose down, disintegrating on impact, killing all 229 crew and passengers on board.

During the crash investigation, the TSB discovered 20 wires that showed evidence of arc-tracking, and it was acknowledged that seven or more of those wires were associated with the In-Flight Entertainment system.

The TSB final report, published on March 27, 2003, concluded that an electrical arc - likely from a wire of the entertainment system – had ignited the insulation blankets.



---------------


In the CBC Fifth Estate broadcast on September 16, 2011, it describes how retired RCMP Sergeant Tom Juby had concerns during the Swissair crash investigation - that it had been declared an ‘accident’ pre-maturely. He presented findings, that he believed, warranted the crash to be treated as a criminal investigation. (This would broaden the investigation to look at other areas).

Juby’s concerns were based on the presence of higher-than-expected levels of magnesium, material commonly linked to incendiary devices. The TSB investigation team considered this information as ‘speculative’, and the RCMP’s reaction was to reprimand Juby.

Though heavy-handed, it’s not really surprising. The dissention of an investigator doesn’t look good, and can throw into question all of the hard work of hundreds of other scientists and professionals.

This had happened before, when the Canadian Air Safety Board (CASB) investigated Arrow Air Flight 1285 that crashed shortly after takeoff from Gander Newfoundland on December 12, 1985, killing 248 US soldiers, and 8 crew members. The nine investigation board members were split 5-4 on the cause. The majority believed that it was due to icing on the wings.The other four dissented, believing that it was the result of an on-board explosion. (Islamic Jihad had claimed responsibility). A judge reviewed the report in 1989, ruling that the available evidence did not support either conclusion. But the public’s confidence in the CASB had been severely undermined, and the investigation had lost all credibility. This led to major restructuring of the CASB into what is now the Transportation Safety Board of Canada.

No one should fault Tom Juby for raising his concerns during the investigation, because that’s what he had been trained to do for his whole career.

Unfortunately, I cannot agree with him in this case.

There were publicly broadcast communications between the Swissair flight crew and air traffic control. In the official transcript, there were no recorded sounds of an explosion. So that pretty much eliminates a bomb. I’ve never heard of terrorist bomb that was preceded by a 20 minute buildup of smoke in the cockpit and cabin.

If it was an incendiary device, then it was very small indeed, not even raising alarm, initially, among the cabin crew. The pilots even asked the cabin crew for their opinion about the source of the smoke, who were unsure themselves.

It’s unrealistic to think that someone would go to all of the effort to discretely plant an incendiary device on an airplane, and not take some kind of credit for it.

For all of the research that I did, the data is entirely consistent with the events leading up to the crash, and it lines up with the conclusions of the Transportation Safety Board of Canada.

I trust the TSB final report.

My anger however is directed at the CBC Fifth Estate producers. They had no right to broadcast this program based on a single premise.

In fact, the show didn’t add any investigative value whatsoever.

There were no comments by the RCMP or TSB officials. No counter-arguments. No views of other scientists.

The show didn’t detail what sort of values of magnesium were measured by Dr. Brown.

It didn’t bother to explore how much magnesium can be expected to be on an airplane. It’s not uncommon for it to be used in engine gearboxes and other airplane components. Did they contact Boeing to find out how many parts made of magnesium would have been on an McDonnell Douglas MD-11 manufactured in 1991?

And there was no one to say whether magnesium parts smashing through the cockpit during a one-second impact would leave questionable levels of magnesium on other parts.

Lastly, there was no suggestion of any physical evidence of an incendiary device recovered from the ocean floor.

The show was purely sensationalistic, and only serves to discredit all of the hard work by the TSB & quality investigative work of other reporters, and to upset the victim’s families.

The CBC Fifth Estate owes them an apology.
 
Posts: 3 | Registered: Fri September 16 2011Reply With QuoteReport This Post
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I would like to thank the above poster, for being one of the finest human beings, I've ever 'met'. I put that in quotes, because I have never actually met this person IRL.

Barbara
 
Posts: 2580 | Location: USA | Registered: Sun April 07 2002Reply With QuoteReport This Post
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Hello. I made an account to post this comment after I watched half of this 'documentary'.

I am absolutely flabbergasted that this documentary was allowed to air, all because of some pissed-off copper with a conspiracy theory chip on his shoulder.

I tend not to express my feelings and thoughts very well when I'm angry, but I just wanted to say that I am so very very sorry for the families and victims of this accident.
None of this should have been dragged out on national television for the purpose of spear-heading one cop's narrow-minded view.

Also, for anyone else reading this comment, it's probably good to note that the FBI ruled out any act of terrorism or 'incendiary device'. Any sort of device would have a) alerted the pilots and cabin crew and indeed the passengers and b) left telltale 'pock marks' on the fuselage.

I'm so sorry that this happened to the families of the victims, and I am so sorry that some awful TV program has given weight to a man who clearly has a chip on his shoulder because he was not given funds or time or allowed to investigate his unsubstantiated claims.

Thankyou.
 
Posts: 1 | Registered: Sat May 24 2014Reply With QuoteReport This Post
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Gem, I really appreciate your post & your thoughts.

Barbara
 
Posts: 2580 | Location: USA | Registered: Sun April 07 2002Reply With QuoteReport This Post
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The person who wrote this original post is a wonderful person, who has always been there for my family. The person is brilliant and has done an amazing amount of work to help figure out what happened to Flight 111. I hope they know how much I appreciate the work they put into telling this tragic story, such as it is. I just wanted to express my gratitude, for their relentless search for the truth.
 
Posts: 2580 | Location: USA | Registered: Sun April 07 2002Reply With QuoteReport This Post
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Bottom line- swissair got greedy, and as a result, 229 died.
 
Posts: 2580 | Location: USA | Registered: Sun April 07 2002Reply With QuoteReport This Post
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This is a very nice and thoughtful message that Cirrus asked me to post on the site.

It's hard to believe that it's been 19 years.

Anniversaries are supposed to be celebrated, but in this case, it is to honor the memories and the cherished lives of loved ones lost.

I never met Tara, but after all this time, I feel like she has been a distant relative. I know that she would be so very proud of her mom.

And I'm impressed by Amy, who has shown such great strength and made her own path despite the hardships, and having missed invaluable sibling life experiences.

To Barbara. We'd never have met in normal circumstances, but now I have a life-long friend for which I have enormous respect. For her incredible perseverance, empathy, and drive to improve aviation safety.

Barbara, through her experience has changed my life, and for which I am forever grateful.

I also appreciate the many people that I've met along the way, including Lynn and John, and the others here that have passionate messages and conversations to share.

To the friends and acquaintances of the 229 important individuals lost, I am sorry. May their spirits be at peace knowing the love that is always there.

Cirrus


/////
 
Posts: 2580 | Location: USA | Registered: Sun April 07 2002Reply With QuoteReport This Post
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