Thu November 21 2002, 11:47 PM
BFThe CTSB vs. The Wall Street Journal
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/Fri November 29 2002, 03:21 PM
BFDecember 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