Swissair crash: cause & closure
Gov't report into Flight 111 crash points fingers at wiring, insulation

By RICHARD DOOLEY
The Daily News

Friday, March 28, 2003



Swissair Flight 111 lead investigator Vic Gerden shows a piece of insulation like the one that caught fire in the jetliner, causing it to plunge into the waters off Peggy's Cove on Sept. 2, 1998.



A spark from a wire surrounded by flammable insulation blankets hidden in the ceiling of Swissair Flight 111 started the fatal fire that sent the plane hurtling into the ocean, killing all 229 people aboard near Peggy�s Cove more than four years ago.

In a comprehensive 337-page report released yesterday at the World Trade and Convention Centre, the Transportation Safety Board found that wires supplying power to the MD-11 aircraft�s controversial inflight entertainment unit showed damage consistent with wire arcing, a type of short circuit generating very high temperatures when its insulation is broken or rubbed off.

But tests showed that silver foil insulation blankets packed around the wires in the cockpit ceiling above the co-pilot�s seat were readily ignited and likely spread the fire through the ceiling before pilots could take action.

�It is important to emphasize here that without the presence of this and other flammable material, this accident would not have happened,� said lead investigator Vic Gerden.

The high-tech entertainment system has long been suspected as the cause of the fire because of the way it was installed and certified.

The board said the certification of non-essential electronic equipment remains a concern.

The entertainment system is no longer in use and the flammable insulation blankets are slowly being removed from about 700 large-bodied jets worldwide still equipped with the insulation.

Gerden said it�s unlikely the entertainment system power supply was the only arced wire, but it�s impossible to pinpoint what other wires arced in the fire-damaged area of the plane.

Board investigators believe that by the time the pilots realized the urgency of their situation, the fire had already spread and that conditions inside the cockpit of the plane were rapidly deteriorating. �Because of the rapid progression of the fire, they would not have been able to complete a safe landing in Halifax,� said Gerden.

Gerden said the fire aboard Swissair Flight 111 was a �wake-up call� for the aviation industry.

The board has recommended tougher flammability standards and stringent tests for material used in aircraft, some of which are now in use. �With today�s report, we�ve asked the bar be raised a bit more,� he said.

The board made 23 safety recommendations, including nine new ones yesterday. It�s the culmination of nearly 41/2 years of work by investigators at the cost of $57 million dollars.

Flight 111 crashed on Sept. 2, 1998 at the mouth of St.Margaret�s Bay, about 10 kilometres southwest of Peggy�s Cove.

Board chairman Camille Theriault called the investigation one of the most complex yet by any safety agency.

It was made easier by the co-operation of hundreds of people, in particular the residents of communities around St. Margarets Bay, many who personally helped the families of victims.�Thank you for showing the world the very best of our national character,� he said.

rdooley@hfxnews.ca

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

Swissair Flight 111 Sept. 2, 1998

The jumbo jet went down off the coast of Nova Scotia, near Peggy�s Cove.

Highlights from the Transportation Safety Board�s final report on the 1998 crash:

The fire that led to the crash most likely started from electrical arcing that began in wiring above the ceiling on the right side of the cockpit.
Investigators found evidence of electrical arcing in a cable associated with the plane�s inflight entertainment system, but were unable to pinpoint it as the definitive cause of the crash.
The arcing ignited flammable cover material on nearby thermal acoustic insulation blankets and quickly spread. The board concluded that certification standards for material flammability were inadequate.
The board cleared the pilots of any wrongdoing. Investigators determined the pilots wouldn�t have been able to land the plane safely even if they had tried to do so immediately after declaring an emergency.
The board made 23 recommendations, nine of them new. Four of them propose improvements to �the capture and storage of flight data� on cockpit voice recorders, flight-data recorders, and cockpit image recording systems.
Results of the Swissair crash and investigation:

New provincial Emergency Measures Organization operations centre in Dartmouth opens after an extensive review of the organization�s response to the crash. Military, coast guard and government agency co-operation in times of crisis is re-examined and improved after extensive debriefing of officials involved with the response to the crash of Swissair Flight 111.
Three memorial sites are designated by the province. One is near Peggy�s Cove, the other is a burial site in Bayswater and the third is the actual crash site near Pearl Island at the mouth of St. Margaret�s Bay.
Cultural and educational exchange to France and Switzerland for Nova Scotia students in 2000 as a gift from European families of victims of the disaster.
The Maritime Muslim Academy is established with a gift from the family of a Saudi Arabian prince killed in the Swissair crash.
The crash investigation focused international attention on several key aspects of aviation safety. The length of time flight-data and cockpit-voice recorders store information; the flammability of material used to insulate airplanes; and the procedures pilots follow when smoke is detected in-flight.
Investigative techniques also changed dramatically with the probe. For the first time detailed computer models were used to map the spread of the cockpit fire that disabled the aircraft. The technique vastly improved the ability of investigators to reconstruct scenarios that contributed to the fire and the subsequent crash.
In the U.S., the crash became the focal point for several groups lobbying the Federal Aviation Administration for improvements to air safety. The International Air Safety Association, founded by Lyn Romano, became the lead organization lobbying for better aviation safety. Romano�s husband Ray was killed in the Swissair crash.

http://www.canada.com/halifax/story.asp?id=A825EA04-4B15-46B0-AFDA-82A130082B08