Doomed flight's legacy: Enhanced fire safety
- South Florida Sun-Sentinel

Swissair Flight 111 probably will be remembered as the jetliner that crashed five years ago because of an in-flight entertainment system.

Which might not be true. But it sounds provocative, doesn't it?

The Canadian Transportation Safety Board recently determined an electrical fire in the cockpit brought down the jumbo near the coast of Nova Scotia, killing all 229 on board.

Yet, the ruling was somewhat vague because it said wiring associated with an in-flight entertainment system might or might not have started that fire.

Because of that ambiguous wording, subsequent news reports implied that in-flight video or music systems could flare up into a raging fire.

Some examples were found to support the notion.

For instance, in March, a Boeing 757 climbed to 14,000 feet, only to have sparks and smoke come out of an entertainment system in the cabin, forcing an immediate landing.

Last August, a flight attendant on a Boeing 767 became nauseated and a passenger threw up after a video system started to spew smoke.

During the past five years, airline workers anonymously reported 60 incidents to a federal aviation safety network, saying in-flight systems emitted fire, smoke or sparks.

So now, anyone who watches an in-flight rerun of Friends might think entertainment systems are seeds for disaster.

Even amicable radio broadcaster Paul Harvey bought into the small wave of panic, saying the airlines might have "outsmarted themselves" by employing potentially dangerous technology, namely, in-flight entertainment.

But something has been lost in the translation here.

In-flight entertainment systems, per se, really aren't dangerous. Rather, their electrical wiring and hookups pose some risk. If that wiring is frayed or improperly installed, it could spark, experts say.

But guess what?

Airliners are loaded with hundreds of yards of wiring for all kinds of systems to provide everything from reading lights above passenger seats to energy for the microwave ovens in the galleys.

Which means, potentially, a fire could start anywhere wiring is bunched, not just in in-flight entertainment systems.

Which brings us to the real legacy of Swissair Flight 111.

As a result of the crash, the airline industry is in the process of upgrading the flammability standards of all materials near wire clusters, as well as ensuring all aircraft have updated and secure electrical components.

After Swissair, which has since gone belly up, the Federal Aviation Administration issued 22 directives seeking to minimize electrical dangers. A major one: The agency instructed the airlines to remove any components covered with a flammable material called metallized polyethylene terephthalate, or MPET.

Although the airlines were given until 2005 to remove this material, MPET is found mostly on older aircraft, such as the DC-9, and those planes are being phased out.

Most new-generation airliners already have built-in protections against electrical problems, such as protective sleeves around wire bunches.

Canadian investigators say an electrical arcing "event," in which a current leaped from one component to another, started the fire on Swissair Flight 111, a three-engine Boeing MD-11, on the night of Sept. 2, 1998.

The jetliner had taken off from New York's John F. Kennedy International, bound for Geneva.

After the plane leveled off at 33,000 feet, the cockpit started filling with smoke.

It was later determined a fire had started in the rear cockpit ceiling. It then ignited nearby flammable materials, such as acoustic insulation blankets.

The pilots donned oxygen masks and prepared for an emergency landing in Halifax, but they had no idea a fire was raging nearby; their cockpit had no fire detection system, the Canadian safety board said.

Perhaps worse, the pilots had no fire-suppression equipment and no rapid-response plan to combat a fire.

The Canadian accident report noted the crew was "essentially powerless to aggressively locate and eliminate the source of fire. .. "

Although they declared an emergency, the crew was soon overcome. The plane plunged into the ocean near Peggy's Cove, Nova Scotia.

The in-flight entertainment system might have been involved in that crash, but the lead investigator said the real culprits were flammable materials and outdated cockpit fire safety regulations.

Now that those gaps are being corrected, we can go back to watching in-flight movies more comfortably.

CD thanks for an interesting article. I do think the writer misses two important points however and overemphasizes just how 'vague' the investigator's remarks were in that final report considering a good deal of it was devoted to the installation and certification of that entertainment system. I'm also wondering what his point is in downplaying the IFEN? He needs to go back and actually read that final report.

As for probable causes the TSB names two things.

1. Metallized Mylar insulation

2. the IFEN (not entertainment systems in general, but the specific one on SR111)

It's findings on general aircraft wiring were relatively minor.

quote:

---

Originally posted by CD:
[qb]...Now that those gaps are being corrected, we can go back to watching in-flight movies more comfortably...[/qb]

---

quote:

---

Originally posted by BF:
[qb]...I'm also wondering what his point is in downplaying the IFEN? He needs to go back and actually read that final report...[/qb]

---

I agree Barbara...

According to this "news" item, it would seem that the problems have all been identified and solved and everyone can go back to business as usual. It's almost like the cliche of the cop standing in front of the accident scene saying, "Move along... Nothing to see here..."

I don't particularly appreciate how the article downplayed the accident, the investigation and the issues that have yet to be resolved. The story to me is nothing but subterfuge and makes me question the motives of the author(s).

quote:

---

I don't particularly appreciate how the article downplayed the accident, the investigation and the issues that have yet to be resolved. The story to me is nothing but subterfuge and makes me question the motives of the author(s).

---

Mark and I totally agree with you. We are scratching our heads at what his motive could possibly be. I spent a fair amount of time on Google today trying to figure out who this guy is and why he would want to defend entertainment systems. The only thing I came up with is that there is a link to this poorly written (IMHO) article on the FAA site.

I'm wondering if he actually read the final report or he received this information second hand. I vote for the later. Thanks for your excellent comments.

Barbara

Here is my letter to the editor (not published) re: Ken Kaye's article:

Ken Kaye�s analysis of the Canadian Transportation Safety Board�s report on the crash of Swissair 111 is partially correct. Media coverage subsequent to the CTSB�s report did imply that in-flight entertainment systems might represent a fire hazard. And Mr. Kaye is correct that this is not exactly what the report says. It says very little about the safety of in-flight entertainment systems in general, but says a lot about the specific system installed on Swissair 111. It was known as the In-flight Entertainment Network (IFEN) and was manufactured by a small company called Interactive Flight Technology (IFT). The TSB�s report cites numerous problems in the design, FAA certification and installation of the system.

The CTSB�s primary goal is the prevention of future tragedies. Canadian law specifically precludes it from affixing blame, or even disclosing details of its investigations to criminal prosecutors. The report goes so far as to state that two specific segments of wire were involved in the �lead ignition event�, one of which supplied power to the IFEN. The other was not recovered. The existence of the second wire is inferred because a single wire could not have arced. So even if the other wire segment were frayed, improperly installed or defective, without the IFEN wire failure, there would have been no fire. The report states that the best way to prevent such fires in the future is to eliminate flammable materials and improve in-flight fire detection and fire-fighting capabilities. But the MPET insulation didn�t cause the fire.

The report also states, �In the configuration that was certified, the IFEN was connected to aircraft power in a way that was incompatible with the MD-11 emergency electrical load-shedding design philosophy and was not compliant with the type certificate of the aircraft.� In other words, the design was flawed and should never have been certified. Both the GAO and the Inspector General of the Department of Transportation are investigating certification procedures, especially the FAA�s use of sub-contractors (who are paid by the applicants) to perform certification.

Also, the CTSB report states in the strongest possible terms that MPET-covered insulating material is a serious fire hazard. But far more disturbing is the fact that this was a known problem. The report states, �In a report dated 24 May 1996, which was forwarded to the FAA, the CAAC [Civil Aviation Administration of China] recommended that the manufacturer be advised that �the insulation blanket installed in the Boeing 737-300, (and) MD-11 airplanes is fire flammable. They should make a prompt and positive response.� � No action was taken. The results were tragic.

Mr. Kaye suggests that the problems are being corrected and we should sit back, relax and enjoy our in-flight movies. We beg to differ. There are thousands of companies involved the construction of all the components that comprise a modern aircraft. Most of them are respectable businesses that take safety and certification requirements very seriously. But for the minority who would breach the public trust, the rules are easy to circumvent. The FAA knew about MPET in 1996 and failed to act. Within hours of the Swissair 111 crash, they were scrutinizing IFT. Cruising at thirty-five thousand feet, it�s too late to do much about any of this, so cross your fingers and enjoy the movie. But on the ground, the prudent air-traveler would be well advised to support real reform of aviation industry regulation and enforcement. Both manufacturers and regulators must be accountable to act decisively to correct known hazards.

My letter to Mr. Kaye, the author of this article:

Mr. Kaye,
I lost my beloved 16 yr. old daughter Tara, in the Swissair 111 crash and my husband and I along with some very knowledgeable individuals have put a lot of time and resources into studying the entertainment system (IFEN) installed on sr111. We have no doubt that this poorly installed system contributed to the death of our daughter as well as the other passengers on that flight. Furthermore the method in which it was certified is highly questionable as is stated in the TSB's final report.

I fail to see that the Canadian investigators were particularly vague on the issue of the IFEN and its role as a contributing factor in causing the crash considering that there were 23 complete pages specifically addressing the faulty installation as well as the problems surrounding the STC and many other references to this system throughout the report, plus 10 appendix entries. Did you ever see the condition of what remained of that aircraft after the crash? When you consider that and the fact that the TSB is not anxious as stated in their mandate to place blame, what they have said about the IFEN is very incriminating.

I thought you might be interested in the following photos (very disturbing) some of which show the shoddy workmanship performed by the installers (Hollingsead) of the IFEN.

http://www.aviationsafetyonline.com/sr111/sr111_pictures.html

Perhaps before you advise your readers to relax and enjoy the entertainment provided on today's flights you should check out the following SDRs issued for 2003. This appeared in Air Safety Week in the August 4th issue.

Shorted, Smoking, Burning, Broken Problems with in-flight entertainment systems in 2003 Based on service difficulty reports (SDRs)

June 16 B737-300 Burning/electrical odor: Climbing through FL 240, forward cabin flight attendant reported a burning/electrical odor. Maintenance found the No. 2 video monitor emitting the burning/electrical odor. Removed and replaced. Operational check good.

April 24 Gulfstream GV Entertainment system controller corroded by leaking battery: During routine inspection passenger cabin entertainment system controller ... and components were being replaced. Prior to installation, a bench check was performed on units and the units failed test. Corrosion was noted on the inside of the unit due to internal 12-volt Gelpack battery leaking. Units installed in the aircraft exhibited signs of corrosion also. Units can be installed at various locations within passenger cabin and may be installed on various other model aircraft (emphasis added).

April 7 B767-300 Projector internally shorted: Enroute ATL/SCL report strong odor of burned plastic ... first two rows of seats of the left side of the cabin. Crew turned off IFE and utility busses. Odor dissipated. Mainte-nance found the forward projector internally shorted. Replaced projector.

March 3 B747-400 Seat unit failed: Enroute to HNL an overheated plastic odor was detected about 45 min. before seat 79AB PVS failed. Replaced UEB [underseat electronics box], SEB [seat electronics box] and console.

March 2 B767-300 Smoke in cabin: AVU [audio-visual unit] in forward closet has internal short. Disconnected AVU and pulled and collared circuit breakers. Replaced VCC [video control console] AVU and when power was turned on found smoke coming from the VMOD [circuit board for VMEBus]. Replaced VMOD and ops check good.

Jan. 27 B767-200 Faulty module: Electrical odor forward cabin vicinity entertainment system equipment. Secured both utility busses for remainder of flight. Found VCC/VMOD bad, shut down IFE system; pulled and collared VCC circuit breakers ... on panel 101 lower E/E [electronics & equipment] bay.

Jan. 18 B777-200 Video unit broken: Enroute SJC-NRT, noted seat 2A video player smoking. Main power to video system turned off. Found personal video player ... case broken at seat 2A and all IFE cables check good. Replaced personal video player at seat 2A. System ground checked normal operation.

Jan. 14 B777-200 Burnt connector: Found burned connector J2 input to VDU 7 ... replaced VDU 7. Pulled and collared C/B.

Jan. 9 A320 Failed capacitor (corroded): Electrical odor mid cabin on final approach. Area inspected with no noticeable defects. Live TV circuit breaker pulled and collared as precaution. Preliminary finding: seat electronics box, internal power supply capacitor C12 appears to have failed.

Jan. 6 B767-300 Entertainment system contaminated cabin: Electrical plastic smell reported by flight attendant just behind cockpit door in video closet. Deactivate IFE per MEL [minimum equipment list]. Removed loads of dust and debris from behind IFE components. Found duty free brochures and several seals from tape box VMOD loaded with dust and lint. Removed all. System ops normal and had no odors from area.

Jan. 2 MD-11 Display failed: Seat 1B video screen had electrical odor. Liquid spilled in area; odor dissipated; screen now inoperative. Reactivated seat entertainment system. Found bad SDU [system display unit] caused SCC [system control console] in audio/video unit to fail. Replaced ... and entertainment sys ops normal.

Jan. 1 B777-200 Monitor failure: Passenger seat 30J in-seat video monitor inoperative, won't turn on. Has a strong electrical smell. Removed monitor, all mounting hardware. ETOPS [extended operations] category 'F': any other event detrimental to ETOPS..
Compiled by AlgoPlus Consulting Ltd

Sincerely,
Barbara Fetherolf
Mother of Tara Fetherolf, Age 16

I did receive a response from Mr. Kaye to my email below:

Hi Barbara

I'm very sorry you lost your daughter in that accident.

Perhaps you're right, that passengers shouldn't feel completely comfortable until all the electrical components of the in-flight entertainment systems are improved.

However, the real point of my column was that Swissair 111 triggered the airline industry to take action to guard again electrical fires.

Ken

I do think it was very nice of him to respond to my concerns regarding his article and his comments do make some sense to me regarding electrical fires. However I still maintain he missed the boat when he dimissed the impact that the IFEN had on the sr111 tragedy. The individuals involved in the IFEN from its conception (IPO-IMHO)to the issues surrounding the sleazy certification and faulty installation, need to be examined under a microscope. I have NO doubt that I would have a 21 yr. old daughter today if it weren't for the IFEN and mylar insulation.

I'm not sure why Mr. Kaye decided to throw the baby out with the bath water when he wrote this article. There would have been far more effective ways to make his point.

I've been following the paper that Kaye writes for ever since seeing this article for the weather updates and news here in Florida and have noticed that this columnist writes all kinds of stories, even about hurricanes. It's interesting to note that it doesn't appear that he is mainly an aviation related writer in the same way as a Gary Stoller (USA Today) or a David Evans of Air Safety Week.