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memorandum


to: AIRLINE X

att.: mr. f.h.w.m. Bloggs [executive vice-president engineering & maintenance staff divisions]

copy:. I.M. Alsoaflunki [president]

from: avandenwal@compuserve.com

CO-AUTHORS: PATRICK PRICE, EDWARD BLOCK, JOHN BARRY SMITH, Aart van der Wal, JOHN SAMPSON, JIM BENNETT, JOHN KING and JAY MILLER 

[ copyright 1999. All rights reserved ]

subject: wiring anomalies

date: 16/01/99

                                       MY REF.: AWA/MD-11/AIRCRAFT WIRING/168

Dear Mr. Bloggs,                                                                                                                                                                   A Listing of the Annexes

You Airline must have noticed that there is growing expert and public concern about the safety of civil aircraft, and in particular about aircraft in which Kapton insulated wiring has been installed.

In fact, aircraft wiring is the Achille’s heel of the industry and the main cause of concern in terms of flight safety (see Annex X). A very important consideration in wire problems is to establish the compatibility of the different types installed on each airplane. (Annex W).

THE ULTIMATE RESPONSIBILITY

It is the intention of this Memorandum is to make you aware of the fact that others have also come across the Kapton issue and ancillary problems, and that also in Europe actions [in the sense of publishing the facts and warning travellers of the dangers involved] may be initiated to increase the awareness of strict standards for safety in the air. Although it should be noted that the sinister issue is specifically Kapton insulated wiring, Kapton is no more than just the tip of the iceberg.

Although most airlines respect the FAA and manufacturer bulletins and national directives, the airlines are ultimately responsible for the safety of their fleet, their passengers and their crews. Airlines need to act pro-actively and not reactively [as they customarily do] to accomplish this safety task, irrespective of the fact that clearly defined/accepted safety standards do not even exist.

A NON-DECISION IS NOT AN OPTION

Like so many other airlines Airline X also operates a fleet of aircraft on which Kapton insulated wiring is installed. Even worse than that, mixed wiring type bundles are installed, with chafing, arc-tracking and flashover as a compounded risk. However, airlines generally fail to inform their crews [let alone their passengers] about the possible consequences of this and by doing so they maintain a Head In The Sand policy. They have deliberately avoided assessing the risks associated with wiring anomalies, a risk that increases by time and by flight cycles. This sinister denial of the problem fits in with executives’ rationalizations of the ultimate cost/benefit analysis of safety initiatives. This is evidently a "decision NOT to make a decision". A non-decision is easier because replacing [Kapton insulated] wiring in an aircraft fleet more or less equals buying a new one in terms of cost. An actual decision to properly evaluate the risks of continuing to operate a Kaptonized Fleet would disclose that action was required. To bring the issue straight to the fore in clear terms: if the problem had been a designed-in metal fatigue located in aircraft landing gear trunnions or oleos, all those would have been necessarily and automatically replaced. That problem would be straightforward, visible and fixable; the wiring issue is by contrast denied, ubiquitous, seemingly insoluble and yet potentially much more deadly.

LEGAL versus MORAL OBLIGATIONS in RISK MANAGEMENT

Of course, the customary response to an issue like this is: "we have done what we have been advised to do [by the FAA in terms of Airworthiness Directives and by the manufacturer in terms of Safety Bulletins] and we take our full responsibility for that". This is simply well short of enough because the facts about aromatic polyimide sheathed wiring deficiencies are very clear. Looking at the question [of adequate response] from the perspective of moral and business standards the answers are not hard to get. In order to prevent inevitable accidents, responsible risk management demands that airplanes on which Kapton insulated wiring is installed should be taken out of service; the contrary business attitude demands that airplanes on which Kapton insulated wiring is installed should be kept in the air. This decision is justified on the basis of maximum mandated maintenance standards. Further rationalization and justification is that flight-crews are "learned" about how to deal with Emergency Check Lists in a "Kaptonized" aircraft.

PUBLICITY

For those flying in "Kaptonized" aircraft the commercial considerations and justifications are highly irrelevant. They would be foolishly depending on the correct moral attitude having been implemented by the aircraft’s manufacturers and the individual airline’s decision makers. Post-crash, this simply means to the public at large that the victims have simply had bad luck. The public does not suspect that the critical decision makers have simply decided, on economic grounds, not to remove "Kaptonized" airplanes from their fleet –because no safety regulator has compelled them to. Each and every day MD-11s , including Airline X’s, filled with Kapton insulated wiring are crossing the oceans. There is no emergency checklist that can cope with the disaster scenario of an arc-tracking fire that is propagated beneath cabin lining by metalized mylar insulation blankets. There will only be an aftermath scenario that, at best, will highlight to the world Airline X’s poor performance in the field of predictable accident avoidance when the sr111 saga inevitably repeats itself. A publicly executed pro-active safety policy is required in order to to convince a dubious public that safety concerns are indeed paramount. Independent leading initiatives on this matter by Airline X will set the standards which other responsible airlines will have to follow – if their safety reputations are to retain credibility.

If airlines persist in the ‘Head In The Sand’ attitude they need to be corrected in public (see Annex Q) because there is fact and truth in the basic statement that ageing Kapton insulated wiring is an extremely dangerous aircraft component. There is no foolproof way to inspect the wiring and no organization has the tools to do so. Apart from the inaccessible areas in an aircraft, it is an impossible task to inspect tightly wrapped bundles of ultra-thin wiring in situ. Disturbing these bundles for ease of inspection has been proven to induce precisely the sorts of faults that can lead to ticking, arc-tracking and flashover.

LITIGATION

The aftermath of litigation in the Swissair crash is predicted to be 229 very large settlements against the manufacturer and the airline. There may well be other defendants. The quantum of the sums awarded will be dependent upon the outcome of the investigation and the apportionment of blame. A conservative estimate is $100 million each plaintiff. It is easily seen that, pursuant to the Swissair court outcomes, insurance underwriters and their actuaries will be very anxious to ensure that repeat accidents do not occur. A likely consequence is that hull and passenger coverage premiums will have a large risk component [and excess] for Kaptonized aircraft. It would be foolish not to – and we know that the insurance industry is not foolish about adverse risk factors. The continuance of a well-publicized Kaptonized fleet will doubtlessly have an adverse influence upon the investment outlook of Airline X shareholders and financiers. In Swissair’s case a plea of ignorance about Kapton may hold water. If Airline X were to have a similar accident in the future, no such plea would be credible and settlement sums would reflect this.

DEPRECIATED FAA PAPERWORK

Aircraft are purchased by airlines on the basis of different criteria. One of them is the approved and stamped paperwork from the design to the delivery stage. Airlines do not care about bench-testing procedures and related criteria as long as they have their approved and stamped paperwork. They need it for themselves and they need it for their insurers and financiers. In the meantime, aviation has globally learnt that the manufacturer’s test bench procedures, as supervised by the FAA, have been woefully inadequate. It has been shown that even after this had been clearly evidenced, the FAA did not want to acknowledge the risks nor validate or change these procedures [the infamous insulation blanket issue]. Again, it all comes down to the Head In the Sand policy in favor of cost/benefit analysis. It must be extremely difficult for organizations with high internal standards to come to terms with the fact that there are a lot of things rotten in Denmark [i.e. at the FAA]. Airline X must realize that it is in its own interests to act upon the facts and not blindly follow the FAA’s debased leadership.

INDUSTRY COLLUSION, CRONYISM and COVER-UP

It is common knowledge that the entire aviation industry is supported by lobbying, influential connections and the social environment of "knowing each other". There are all kinds of intertwined connections, cozy collusion with so called "air safety" organizations and even an empathetic media. It is therefore not beyond belief that, in this atmosphere of economistic and optimistic cronyism, an air crash needs to occur before any measures are taken. Again: the cost/benefit analysis rules the airwaves. Post-crash, the whole circus starts afresh: the shocked aftermath, the protracted investigation, the indeterminate conclusions [Probable Cause] and the watered down recommendations. It is dismissed as a "once-off" - until the next crash happens.

The Swissair SR 111 disaster happened in Canada. This almost excludes the possibility of an NTSB/FAA cover-up. The Canadians do not have to protect the native aircraft building industry, the Americans do. There is more than just a slight chance that each and every stone will be turned over by the Canadians. Experts have in the meantime supplied the Transport Safety Board of Canada with the real facts about Kapton insulated wiring, resetting tripped circuit-breakers and the hazards of Kapton and Tefzel wiring bundled together. Independent investigations will be conducted by the Canadians. STC certification procedures will be checked, and so on, and so on. This will be done, not because airline financial liabilities are so important [insurers will still be obliged to cover them], but because of ongoing MD11 flight safety concerns. (see Annex I & Annex K)

A COMPROMISED LEGAL STANDARD

Although U.S. wiring experts, military engineers, airlines and media have over the years pointed out on many occasions that Kapton insulated wiring is a hazard to air safety, neither the FAA nor the airlines have taken appropriate action to improve or even to verify the compromised safety standards. Airline X is no exception. No pro-active substantive measures have been taken by any party – except the military (whose bottom line, notably, is not a financial one). Instead, a commercially correct "blinkered" policy is rampant, based upon the flawed logic that accident statistics do not yet justify the cost. It does not seem to be significant to the aircraft industry nor the airlines specifically, that millions of passengers entrust their lives to airplanes that are safety compromised; in even stronger terms: to airplanes that do not even legally meet the minimum standards of U.S. Federal Aviation Regulations [FAR’s] 25. In part these specify that registered public transport airplanes may not have design features or details that experience has shown to be hazardous or unreliable. The suitability of each questionable design detail and part must be established by tests. Materials: The suitability and durability of materials used for parts, the failure of which could adversely affect safety, must be established on the basis of experience or tests. All components must conform to approved specifications [such as industry or military specifications, or Technical Standards Orders] that ensure they have the strength and other critical properties assumed in the design data; materials and component suitability tests must take into account the effects of environmental conditions of not only temperature and humidity but also the effect of vibrations, hydraulic fluids, grease, oil, cleaning solvents and de-icing agents expected to be encountered in service.

FAR 25 on WIRE

Note: aircraft wire is composed of a metal conductor encased inside an insulation MATERIAL. Wiring types are conventionally named after their conductor wire’s outer insulating sheath (Annex W). If that chemically constructed insulation material becomes the fuel for a fire and smoke, due in part to electrical ignition, then that aircraft wire FAILS to meet FAR 25. This regulation applies to all commercial aircraft. Electrical Systems and Equipment Sec. 25.1351 General [a] Electrical system capacity: The required generating capacity, and number and kinds of power sources must--- [1] Be determined by an electrical load analysis; and [2] Meet the requirements of Sec. 25.1309. [b] Generating system. The generating system includes electrical power sources, main power busses, transmission cables, and associated control, regulation, and protective devices. It must be designed so that--- [1] Power sources function properly when independent and when connected in combination; [2] No failure or malfunction of any power source can create a hazard or impair the ability of remaining sources to supply essential loads; [3] The system voltage and frequency [as applicable] at the terminals of all essential load equipment can be maintained within the limits for which the equipment is designed, during any probable operating condition; and [4] System transients due to switching, fault clearing, or other causes do not make essential loads inoperative, and do not cause SMOKE or FIRE HAZARD. [Doc. No. 5066, 29 FR 18291, Dec. 24, 1964, as amended by amendment 25-41, 42 FR 36970, July 18, 1977; amendment 25-72, 55 FR 29785, July 20, 1990]

Electrical equipment and installations: [a] Electrical equipment, controls, and WIRING must be installed so that operation of any one unit or system of units will not adversely affect the simultaneous operation of any other electrical unit or system essential to the safe operation. [b] Cables must be grouped, routed, and spaced so that damage to essential circuits will be minimized if there are faults in heavy current-carrying cables. . . . . Doc. No. 5066, 29 FR 18291, Dec. 24, 1964, as amended by amendment 25-41, 42 FR36970, July 18, 1977; Amended 25-42, 43 FR 2323, Jan. 16, 1978] see Annex N

After reading the examples of smoke and fire at Annex F, it will be clear that most insulation of aircraft wire could meet the certification of FAR 25. [Reference Ms. Pat Cahill, FAA's test documents: Report No. DOT/FAA/CT-89/21 Flammability, Smoke, and Dry Arc Tracking Tests of Aircraft Electrical Wire Insulation. Report No. DOT/FAA/CT-TN94 / 55 Electrical Short Circuit, and Current Overload Tests on Aircraft Wiring, Author Patricia L. Cahill March 1995 Final Report 13 pages Sponsoring Agency, FAA Tech Center, Atlantic City, NJ.]

AIRCRAFT CERTIFICATION

The final step in aircraft certification is the issuance of the Certificate of Airworthiness for each and every aircraft off the U.S. assembly line, testifying proper design and construction, and all inherent qualifications for safe commercial use in the longer term. The MD-11 operated by Swissair [Flight 111 New York-Geneva] was built and certified in the United States, cruising in U.S. airspace and crashing beyond U.S. territory on September 2. 1998.

Airworthiness Directives [ADs] are issued by the FAA . If design problems are revealed when the plane is in service, and they result in an unsafe condition, Airline operators and aircraft manufacturers need to correct the problems via an AD. Although the FAA has no legal authority outside the United States, there has never been any question about non-United States operating airliners having to meet the requirements of that AD. Because this is not only a matter of safety, but also a matter of qualifying for continued insurance coverage, most insurers refer generically to the requirement for safe aircraft operations in their policy conditions. Most ADs are drafted in consultation with the aircraft manufacturer. Compliance time limits will depend on the situation [degree of safety hazard], whether the problem needs to be dealt with immediately, by a certain date or, more usually it will be spelt out that a specified amount of in-service time is allowed in which to deal with it. A Part 121 operator must have FAA approved training and maintenance programs as well. The maintenance program must specify the intervals for inspections and maintenance.

Records must be kept and must be accessible for FAA inspection. The training programs for flight-crew include emergency procedures, either in airplane or simulator. Airline X is a Dutch company and in the strictest sense therefore not subject to United States Federal Law and therefore [also] not to FAA ADs, and FAA’s approved training and maintenance programs. However, the company is known in the industry for maintaining extremely high standards in terms of aircraft maintenance and flight and cabin crew training courses. Airline X operates a modern fleet and has an excellent safety record. The company is subject to Dutch law and conventions, and bound to international agreements ratified by the Dutch government.

THE FAA & SAFETY IN GENERAL

Although the FAA is charged with responsibility for setting and enforcing minimum safety standards in the United States aviation industry, the primary and ultimate responsibility for safety rests with the carriers themselves, irrespective of their nationality and base. Safety is the top priority for national and international airlines. There is joint effort through the Air Transport Association in observing a long agenda of safety-related programs. Maintenance programs have been internationally standardized because they have been developed jointly with the aircraft manufacturers. It is in the interest of all concerned that maintenance programs comply with mutually set standards.

PRODUCT LIABILITY

There can be a manufacturing defect [the product is not built as it should]; there can be a design defect [the deficiency involves the entire product line.] DuPont [the makers of Kapton insulated wiring] and the aircraft manufacturers were, at the time of manufacture and use, as well as thereafter, aware of the risks associated with the use of the product. However, they ignored warnings from leading wiring and other aircraft experts and failed to notify the airlines about the risks of using Kapton insulated wiring in civil transportation aircraft [see next chapter.]

KAPTON INSULATED WIRING CONCERNS HAVE RESURFACED

During the early investigation of the SR 111 disaster various experts were pointing out that the smoke in the cockpit might have been caused by Kapton insulated wiring. The aromatic polyimide wiring insulation [Kapton being DuPont’s brandname for this product] was in use in both civil and military aircraft until the end of 1993. Several operators, and the United States Navy and Canadian Armed Forces in particular, then began to realize that this insulation was the cause of increasing number of fires and failures in their aircraft. They therefore banned its use much earlier than that. On 30 June 1977, Trans World Airlines sent a letter to Boeing Aircraft citing Kapton as a safety hazard in their L1011 fleet and stated that they would strongly object to its future use on any TWA aircraft. The FAA claims not to know about that letter. Indeed the FAA claims that there is no cause for concern about Kapton. However, a comparison test between Kapton and its modern replacement TKT [Teflon-Kapton-Teflon] is a very convincing demonstration of Kapton’s tendency to allow arc-wiring tracking or flash-over. Video tapes have been published showing Kapton and TKT wiring on the test bench. The DC-10 [and 20 other types of commercial aircraft, 31 military types, plus 12 spacecraft] had Kapton wiring in special applications [e.g. power feeder cable, generator leads, high density wiring, SWAMP areas, high temperature areas, avionics -- all the areas you wouldn't want to put it!]

Due to the nasty arc tracking and topcoat flaking problems associated with Kapton, the USN has had it ripped out of their E2C Hawkeye, F-14 Tomcats and others. The Canadians are now removing it from their [C]F-18s and P-3s [CP-140]. Taking all this into consideration McDonnell-Douglas installed Kapton in the MD-11, with full knowledge of arc tracking and topcoat flaking problems associated with it. The airlines did not take any action, other than meeting the requirements as drafted by the FAA [ADs] and the manufacturers [SBs]. If they continue to accept this situation the airlines [and also Airline X] are simply pretending to maintain high safety standards - that in reality do not exist. This is called "lip service" and is the highest form of hypocrisy where safety is paramount. Courts are very acutely aware of [and sympathetic to] plaintiffs who can successfully allege airline prior knowledge of dangerous pre-existing conditions. It is worth noting that in these circumstances the burden of proof shifts to the defendant. In other words, airlines will in future have to prove that they were not aware of a particular safety hazard [such as Kapton’s well publicized characteristics]. An airline’s credibility and integrity thereby becomes a constituent element in any defended litigation. Ignorance is no longer a defence. Swissair has confirmed that insulation lining which played a role in fires on four other jets was installed on the Flight 111 MD-11. Boeing had recommended its removal many months before.

METALIZED MYLAR INSULATION BLANKETS

Although metalized Mylar insulation is FAA approved, McDonnell-Douglas recommended in 1997 that it be replaced with a more fire-retardant type at " the earliest possible maintenance". The current state of affairs in the investigation of Swissair Flight 111 is that TSB investigators have found evidence of heat-damaged wires and structure as far back as the forward galley, ahead of the first-class compartment, and that there has been recovery from the crash site of wire wrapped in aromatic polyimide tape insulation that displays a considerable amount of heat damage.

THERMAL INSULATION BLANKETS MET FAA APPROVAL

McDonnell-Douglas, the MD-11 manufacturer, recommended in 1997 that the insulation be replaced with a more fire-retardant variety at "the earliest possible maintenance period".

Boeing [which merged with McDonnell-Douglas in 1997] told the Washington Post it does not know how many of their MD-11’s, originally equipped with the metalized Mylar insulation blankets, have been retrofitted with a different type. TSB’ s investigations revealed that small amounts of insulation of both types had been found. As part of the investigation, officials have learned that the Mylar insulation blankets allowed fires initiated by electrical shorts to spread rapidly aboard three different aircraft from

1993 to 1995, in China, Denmark and Italy. All occurred on the ground and no one was injured. In a fourth incident, maintenance crews started a fire when hot metal chips from an air drill ignited one of the blankets. This indicates that material testing by the supplier of these insulation blankets and the aircraft manufacturer have not been up to the required standards for this vital part of aircraft construction [the blankets are used to insulate the aircraft from heat and noise]. See Annex O

The FAA recently announced that it was also recommending that metalized Mylar insulation blankets be taken out of approximately 12,000 airliners because of its unsatisfactory flammability characteristics. This sound-proofing thermal insulation material fills the void between the aircraft metal skin and the cabin or flight-deck lining. The announcement shows the FAA at its worst by publicly admitting that the original token test procedures used for Mylar metalized insulation blankets did not show those unsatisfactory flammability characteristics. Either these test procedures were no good, or the manufacturer changed the chemistry/structure of the product later in the process.

1995, June. While the crew of a Chinese airliner were preparing to start engines, they noticed smoke from the electrical and electronics bay [E/E] that is below the cockpit in the MD-11. The investigation revealed that "molten metal, from arcing wires in the bay, had fallen on the blankets of insulation under the bay, igniting them." The Chinese official, Wu Xiangru, who sent a report to the American FAA, said that " There was extensive flame propagation from the insulation blankets up to the E/E bay with widespread damage." The Chinese officials did their own testing on the supposedly fire-safe insulation blankets. They discovered the insulation would burn if it was exposed to high heat. Thus, they suggested to the FAA that they review their testing standards that allowed such a fire to happen. The FAA’s response was all too familiar: it maintained its testing standards were adequate, noting that the Chinese tests were more extreme than the FAA’s requirements. That, despite the fact that there were 3 other incidents, in Douglas Aircraft types, where insulation blankets caught fire after being exposed to arcing electrical fires [ twice] and hot shavings from a mechanic’s drill motor [once]. Although the FAA failed to act, after learning of those 4 fires, Douglas did put out a service bulletin which recommended the replacement of the metalized Mylar insulation blankets, at the first maintenance opportunity, with another type. That service bulletin was issued about one month after a heavy maintenance check was finished on the Swissair MD-11 that crashed in Nova Scotia. Swissair decided, after receiving that bulletin, not to replace the insulation because "it was a non-priority recommendation", that had never been mandated by the FAA.

ARC WIRE TRACKING

The nature of the aromatic polyimide wire insulation [Kapton] is such that with age it dries out and becomes brittle. Hairline cracks can occur, exposing the metal conductor. This can happen quite early on where the insulation is damaged or the wiring loom is stressed by being bent around [say] a ninety degree bend. Because you have upwards of two hundred of these wires gathered together in each bunched bundle and you only need one instance of arc-wire tracking to start the flash-over effect, the hazard is very real. It can generate instant temperatures of over 5,000 degrees Kelvin. Because these wiring bundles or looms are routed over and through the flammable insulation blankets there is the risk of a fire being started and propagating in all directions beneath the cabin lining.

There is approximately 260 kms of this wiring in a modern airliner, the majority of it is energy carrying. The amount of wire that goes into an airliner has increased exponentially with the seat-back entertainment units, floor lighting and computerized flight decks. You cannot effectively inspect it because the cracks in the insulation are so fine - and you can’t "access a large percentage of it because it runs through conduits or bulkheads or inaccessible areas. Even bore-scoping will not work. Moving it can cause the very damage that you are trying to detect. It is unfortunately part of the structure and cannot be removed like an avionics box for bench-testing". It would simply be cheaper to trash the aircraft and buy a new one.

THE CHAIN OF CAUSATION

Boeing and the FAA have strongly suggested that airline operators remove the Mylar insulation blankets and to replace them with a safe non-flammable alternative. Unfortunately a suitable replacement is not available and reportedly will not be for some considerable time. It is doubtful, however, if this initiative would break the chain of events leading to a cabin or flight-deck fire and lethal toxic smoke because a Kapton arc-tracking fire may well take out a whole wiring loom, an entire bus or the whole electrical system. The MD-11 and other pure fly-by-wire aircraft with dinky sidestick controllers cannot be flown in a total electrical failure situation. Provision is made for individual components to fail, but something as fundamental as failure of the wiring and the system itself was not taken into account in the design of the fly-by-wire glass-cockpitted aircraft. For instance, in some aircraft the hydraulic pumps that operate all the flight controls are electrically driven or controlled. There is no fall-back position because there was supposedly sufficient redundancy built in by having a generator on each engine plus a deployable air-driven one.

THE sr111 IN-FLIGHT ENTERTAINMENT SYSTEM

TSB’s technical examination of recovered materials from Swissair Flight 111 has revealed that some of the wiring and structure, located in the cockpit ceiling and its surroundings, showed signs of heat damage. Some of this wiring is associated with the aircraft’s In-flight Entertainment [IFE] system. After discussions with investigators from the NTSB and the Swiss Federal Aircraft Accident Investigation Bureau, Swissair decided that as a precaution, they would immediately disconnect the IFE system on all of their aircraft equipped with this particular system. Information available at this time indicates that the Supplemental Type Certificate [STC], under which this system was installed, is unique to the Swissair fleet. However, it is not yet clear if the IFE system was installed/hooked up with the STC certification still not formally completed. This might also include accusations in the press that Swissair overlooked or ignored McDonnell-Douglas documents about research in this field when it ordered the IFE system.

The IFE system wiring is covered in ethylene tetrafluorethylene insulation, known as Tefzel. The U.S. Navy considered Tefzel as its standard maintenance wire before it effectively banned Kapton in 1987. The Navy’s chief electrical engineer found Tefzel was too soft. The Navy opted for a tougher form of Tefzel that was not so susceptible to chafing and other wear. Standard Tefzel is rated at 150 degrees C, while Kapton is rated at 200 degrees C. Mixing Tefzel and Kapton together is not recommended, because Kapton has a more abrasive resistance and will therefore sandpaper Tefzel during airframe flexure due to its softer material. Once that sandpaper effect takes hold, the protective insulation is removed, leaving the exposed metal wires to wreak havoc. This was also determined by the MD-11 makers in the late seventies. Company engineers noted significant wear in bundles mixed with Kapton. TSB investigators will therefore no doubt also take this into very serious consideration. [The company that has manufactured the IFE, Interactive Flight Technologies Inc., Phoenix, Arizona has announced that it is branching out into dry-cleaning and is considering getting out of in-flight entertainment.]

WAS VALUJET 592 a WIRE ACCIDENT?

According to leading and outspoken experts on aircraft electrical systems, the problem of eroding and flammable insulation on aging aircraft electrical systems is industry-wide and is serious enough to warrant a massive inspection program. " We have a wholesale problem of degraded wire -- and a track record of being surprised" said Edward Block, a former Department of Defense aircraft wire and cable specialist. His concerns are mirrored by those of Patrick Price, a retired wire expert with a 36 years career at Boeing, who said flatly, "You have an incendiary bomb flying on most airplanes". They both believe that electrical arcing triggered the fire that led to the crash of ValuJet flight 592 in May of 1996. The 27-year old DC-9-32 had been experiencing electrical problems throughout its final day. Shortly before the doomed airplane's final plunge into the Florida Everglades, first officer Richard Hazen reported an electrical failure and thick smoke aboard the aircraft typical of an electrical fire (see Annex A). In recent years there have been a number of aircraft fires and fatal accidents from electrical faults. Among the common threads are aircraft age and the installation of wiring lacking durability and fire resistance. See Annex P

THE FAA ACKNOWLEDGES UNSAFE WIRING

The White House Commission, headed by Vice President Gore, has made specific recommendations regarding aging wiring in civil aircraft. In response to those recommendations, the FAA is planning to study issues associated with aging wiring, conduct any research necessary, and take appropriate action...."Our study will consider the issues raised by Mr. Block and others, as well as all service experience to date with all types of wiring". Thomas E. McSweeny Director, Aircraft Certification FAA May 21, 1997 letter to Rep. James Greenwood [R-Penn.] This study is already under way. Indeed, the Gore Commission on aviation safety and security recommended expanding the FAA's aging aircraft inspection program to include non-structural items such as electrical systems. The Commission's Feb. 1997 final report expressed concern about the longevity and reliability of electrical wires, connectors, wiring harnesses, and other electrical components on geriatric aircraft. As a direct result of the Commission report, the FAA plans to undertake a major examination of the problem.

AN ALTERNATIVE TO KAPTON

Price conducted at Boeing the qualification tests on the hybrid-constructed wire known as TKT that has been installed on all Boeing 737s and 757s built since 1992. TKT is the acronym for the Teflon-Kapton-Teflon construction of this wire's insulation. The Teflon gives it high resistance to chafing, the Kapton provides superb electrical insulation protection, and the layered wrapping around the wire core gives off very little smoke in the event of a fire.

Other types of wire, installed on aircraft prior to the development of TKT, have demonstrated a pernicious tendency to crack, craze, and break down over the service life of an airplane, causing electrical arcing and so-called "ticking faults" (intermittent sparking) which can ignite fires. In some cases, the insulation itself contains oxidant and fuel. Kapton, for example, if it catches fire can actually fuel the blaze to a blowtorch-like intensity. One of the combustion by-products of aromatic polyimides is phosgene, a deadly gas.

Price maintains that arc tracking is not only a dangerous fire hazard, it creates an electrical surge that can short out an autopilot or cause a thrust reverser to deploy. Another symptom of degraded wire insulation, the emission of spurious signals, can cause spoilers to stick in the up position, yaw dampers to perform erratically, unintended autopilot commands, and cockpit warning lights to activate. For all of these reasons, the integrity of the insulation over the life of the airplane takes on added importance.

High-Temperature Aircraft Electrical Wire: PVC, Poly-X, Stilan, Kapton ,TKT.

Price is so high on hybrid-constructed wire like TKT, that he believes it should be required on all new aircraft. For in-service aircraft, Price recognizes that it would be "horribly costly" to replace their electrical wiring (Annex W). Instead, he believes that lightweight sensors should be placed at critical points in older aircraft to detect the spurious radio signals [static] created by arc tracking. "They would function like a stall warning system, giving the pilot time to effect an emergency landing", Price said. "If you get arc tracking in a power bus, and the power stays on those wires, it'll burn a hole right through the airplane's structure -guaranteed".

Ed Block argues for a careful four-step look at the problem:

  1. Acknowledge the problem. The industry, he said, is "in denial right now", about the dangerous condition of electrical systems on older aircraft. Block maintains that hundreds of aircraft built 10 and 20 years ago are flying today with cracked wiring and dangerously flammable insulation.
  2. Find out how many aircraft are affected. "We need to map out the numbers and types of aircraft flying with each type of wire insulation", he said.
  3. Conduct teardowns. "We need to examine in detail the wiring on at least five aircraft of each type", Block urged. He said wholesale insulation cracks and bare spots were found on the wiring of the Philippine Air Lines 737 that exploded in flames at Manila airport in 1990, killing eight. These detailed biopsies, as it were, of aircraft electrical system should be conducted by independent organizations, Block said. He suggested the high-temperature wire committee of the National Electrical Manufacturers Association as one group qualified to conduct such an examination. The Society of Automotive Engineers is also eminently qualified to undertake such an effort, according to Block.
  4. Obtain more knowledge of the problem. The FAA's technical center in New Jersey has conducted extensive work on electrical wiring, fire safety and arc tracking, but in a 1995 letter to Block, an official at that FAA center conceded, "We have not, nor have we been requested to study stray signals from degraded wire".

That situation, of course, can change given that the Gore Commission has identified the issue as a potential safety problem. The center's 1995 study of electrical short circuits and current overloads on aircraft wiring [report code no. DOT/FAA/CT-TN 94/55 dated March 1995] clearly suggested the need for more study. For example, it was found that "circuit-breakers may not protect wire from ticking faults". Above all, Block said that mechanics and post-crash investigators need better training. These individuals, he maintains, need to be more knowledgeable about what to look for when inspecting and repairing wires, or when conducting post-mortems of electrical system malfunctions and fires. However the "outing" of Kapton by the sr111 accident has led to fundamentally opposed "official" and "expert" views about the threat posed by Dupont’s premier wiring insulation product. (See Annex B)

 

THE CRASH COALITION

Price is now a member of a group called CRASH [Coalition Revealing Air Safety Hoax], which counts among its members FAA-licensed mechanic John King and Ed Block who have spoken out about the dangers of Kapton. Mr. King says there is plenty of evidence that electrical problems have caused airline crashes and unscheduled landings over the past two decades and he suspects wiring insulation is behind them. Mr. King spent a year culling information on 37 smoke- and fire-related crashes or incidents from FAA databases or technical lab reports and the U.S. National Transportation Safety Board databases. The incidents stretch from the 1983 crash of an Air Canada DC-9 in Covington, Ky. - 23 people were killed and 16 injured - to the Sept.2 Swissair crash. Richard Williams, the president of Aviation DataSource Inc. in Denver cautions against using the current crop of FAA and safety board data to support theories about Kapton. The company - which provides aviation database information, including FAA airworthiness directives, to maintenance professionals and facilities around the world - analyzed the FAA's Service Difficulty Report [SDR] database for an American newspaper last spring. It found 1,089 cases out of 360,000 in which flames, visible fire, smoke, fumes or odor led to unscheduled landings. He says media outlets and others have since linked the figures, which date to March 1990, to Kapton when the database doesn't even explain what caused the incidents. When Mr. Williams did more in-depth research after the Swissair crash, he found 1,200 incidents in which flame, fire, smoke, fumes or odor, specifically in cockpits or cabins, prompted unscheduled landings. Williams says media outlets and others have since linked the figures, which date to March 1990, to Kapton when the database doesn't even explain what caused the incidents. When he did more in-depth research after the Swissair crash, he found 1,200 incidents in which flame, fire, smoke, fumes or odor, specifically in cockpits or cabins, prompted unscheduled landings. But they were linked to a range of problems: electrical wire, navigation equipment, burnt food in galleys, passengers smoking in washrooms, heater malfunctions, and cabin lighting. Even when electrical problems were noted, he says, none mentioned Kapton as the cause. Williams says the FAA databanks are too imprecise for their contents to be used as the basis for a good computer study. "The big issue to be made here is that there is no evidence from the statistical data point of view that directly links wiring or Kapton-insulated wiring with a significant number of problems" he said. "I did another study where I found that 47, and only 47, of the 1,089 that we produced ... were electrically related and there was no way to tell whether they resulted from a failure of the insulation".

While Williams considers the FAA data inconclusive, he says media across the U.S. have " used FAA's data and the NTSB data and to a great extent our data to draw improper inferences. We do seriously believe that Kapton is a problem. We seriously believe that electrical wiring in aging aircraft is a problem, but we can't take the existing database and use that as the sledgehammer". Mr. Price, however, is convinced the insulation is a time bomb. And, he says, there's a strong chance it contributed to the Swissair disaster. "The most important part of the evidence that they've found so far . . . was from the pilot . . . when he said we're getting smoke in the cockpit". Anytime you get smoke in the cockpit, you can bet 99 per cent that it's an electrical fire that occurred. "That's either the wiring and/or electronic equipment that had an electrical short in it. It isn't that the captain was smoking a cigar".

SR 111 crashed outside United States territory. Therefore, neither the NTSB nor the FAA is directly committed to investigating the crash. The Transport Safety Board of Canada conducts all investigations and the chances that there will be any cover-up is minimal. The TSB has no interest whatsoever with the strong economic lobbies that can overrule on safety issues and enforce their cost/benefit analysis in the United States.

The FAA is however involved from another perspective:

Boeing engineers concluded that Kapton was completely unsuitable because, when wires arced within the Kapton insulation, Kapton became a carbon track, allowing further propagation of the electrical arcing, much like a dynamite fuse. This clearly made Kapton a bomb waiting to go off in any aircraft in which it is utilized. It is indefensible that both the FAA and the manufacturer of the MD-11 would permit the use of electrical wiring in a civilian, passenger-carrying airliner, knowing that in an aircraft in which the crew is equipped with an ejection seat, the material had been found to be unsuitable because of its fire and arcing propagation characteristics. It may also be considered irresponsible that prominent airlines [including Airline X] operate aircraft that house a known prospective danger to passengers. [Kapton was in use in both civil and military aircraft until the end of 1993. Several operators, and the United States Navy and Canadian Armed Forces in particular, then began to realize that this insulation was the cause of an increasing number of fires in their aircraft. They therefore banned its use.]

Wiring problems on board MD-11’s were the subject of two FAA AD’ s in 1996 and 1997. They warned of potentially hazardous wiring in the cockpit and in a rear console for flight attendants. However these directives dealt with configurations, not with materials.

WIRE PROBLEMS CAN BE PREDICTED

The technology exists to predict when cracks will occur in wire insulation; whether it will be employed by airliners may depend primarily on the actions, or reactions, of government regulators.

Unquestionably, aircraft wiring is a hot topic in the wake of the crash of Swissair Flight 111, where more evidence is surfacing that the crew was faced with a massive electrical malfunction, perhaps aggravated by wiring with a record of substandard in-service durability [see Air Safety Week, Sept. 7, 1998]. A $125 million lawsuit filed by the father of one of the dead passengers charged that the wiring on the accident airplane was "defective and unreasonably dangerous".

In addition, the Federal Aviation Administration is nearly ready to announce an expanded program of wire inspections of aging aircraft. In fact, the scheduled announcement of this expanded inspection program has already slipped from the end of July but could occur before the end of this month. However, according to internal documents obtained by Air Safety Week, this program may well be limited to those aircraft more than 20 years old, although the Swissair MD-11 that crashed recently was only seven years old. One aspect of the industry effort will involve sampling the condition of wiring on 10-20 high-time aircraft by the end of May, 1999, to provide initial insights into the overall condition of the fleet.

MOVING BEYOND WIRING INSPECTIONS TO PREDICTIONS

This effort will detail the incidence of chafing, nicks and cuts. However, techniques also exist to "predict" the amount of life remaining in aircraft wire [see ASW, July 27 and http://www.aviationtoday.com/reports/wiring.htm ]. The predictions - which project the probability of the insulation becoming breached [cracked into the conductor] in the future - can be used to target maintenance programs to replace wire in key locations before problems occur. Such scheduled maintenance could offer considerable cost savings over unscheduled maintenance that may be required after problems are found.

The methodology has been developed by Dr. Armin Bruning, Ph.D., a recognized expert in aircraft wiring. Bruning heads a small company in Herndon, Va., that which specializes in aircraft wiring assessments. A full description of the procedure is at Annex C.

"MINOR" INCIDENT IN BANGKOK (the SR 111 Precursor event?)

Swissair have admitted that they had a minor fire in one of their MD11 aircraft in Bangkok on 3 August, when a DC bus-tie sensing relay malfunctioned during routine maintenance. Swissair decided to change these relays in their entire MD-11 fleet. On 4 August the electrician incorrectly installed the new relay in the accident aircraft causing a short circuit. The installation was then rectified and checked serviceable. This may have been relevant to the 2 September crash. Unfortunately, with Kapton wiring a short circuit can damage the insulation and other components downstream of the fault and bring about the precise conditions for a later case of arc-wire tracking. It is a reasonable bet that this was the precursor to the 2 September event….and particularly because the accident aircraft was only approximately eight years old and the Kapton aging process was probably not yet adequately significant.

All the details about the relay malfunction on August 3/4, 1998 in Bangkok, where the mechanic installed the relay incorrectly and shorted out the system in the accident aircraft, need to be investigated thoroughly. He later re-installed a relay correctly and the system checked out as being OK. But did he trip a circuit-breaker? Did he re-set the circuit-breaker before or after making a correct installation? Was the wiring checked out to verify no damage had been encountered? Were all engines and generators operating (with a full elec load) for the supervisory check that certified the installation as serviceable? If not, with a bus-tie sensing relay, the check was obviously invalid. Was the IFE connected to the same power bus that the bus-tie relay caused a short-circuit in? It is possible, that if the essential bus that had the relay incident was the one that they connected the IFE to, and it was checked out as being OK with the relay correctly installed, after resetting the circuit-breaker, the Kapton wiring was damaged and ready for an electrical arc tracking condition. That is why these answers are vitally important. It is a real possibility that the IFE wiring was damaged, due to it being connected to the damaged essential AC2 power bus. When the Kapton wiring had a flashover, an electrical fire took off. The IFE wiring, being in close proximity to the Kapton wiring, would have been involved as well.

SWISSAIR’S HEAD-IN-THE-SAND POLICY

Whatever starts the fire, if it becomes ‘dense, continuous smoke’ the flight-crew will be unable to see their instrument panels nor any external visual references. They lose control of all on-going procedures, lose orientation and may suffer disabling toxicological effects. The FAA official perspective (see Annex E) is that, in this event they are surely doomed- i.e. nothing can be done to prevent this outside possibility from leading to a crash. See Annexe L & Annex M

I am in possession of a fax message on Swissair letterhead dated 20 December 1991 demonstrating Swissair’s alarm regarding long standing concerns about blinded pilots not being able to see outside or the critical flight instruments when dense smoke fills the cockpit. (See Page 13 below)

From Swissair Operational Engineering OCT, CH-8058 Zurich-Airport, Switzerland

F. Hottger, unit OCTZ.

To Vision Safe Corporation, Kaneohe, Hawaii, Att. Mr. B. Werjefelt

Date: 20.12.91 - Page 1 of 9.

Text: Subject: Accident of SR CV990 A/C Feb. 21.1970

Dear Mr. Werjefelt,

Enclosed you will find the requested information about the accident.

Sincerely,

R. Hottger [signature]

The 1993 letter (text below) from Swissair's safety chief (Rentsch) to Werjefelt demonstrated Swissair's alarm and long standing concerns about blinded pilots not being able to see outside or the critical flight instruments when dense continuous smoke fills the cockpit. The 1970 tower-to-Swissair flight 330 transcript (text at Annex D) echo the words of the Swissair flight 111 crew twenty-eight years later as each crew tried to deal with dense continuous smoke in the cockpit (see also Annex J) .

In taped phone conversations with Werjefelt the FAA claims to have no plans to help pilots blinded by dense continuous smoke. Pilots are "not expected to see" if they simply can’t. EVAS technology was rejected by the FAA because there were not enough 'reports' or American accidents (until ValuJet). Non American carrier incidents / accidents (deaths) would not result in American regulatory actions. Non American carriers seldom act without FAA actions (ADs, Bulletins, etc). Perhaps European lives are worth even less than American lives?

No matter what the initiating event; (trash can or wire bundles) what do the pilots do with 'dense continuous smoke' ? According to those FAA policy maker (Broderick's) transcripts with Werjefelt, they 'aren't expected to see' (text of taped Broderick conversations are at Annex E). That sort of weird logic defines a crash as being inevitable and unavoidable – which simply is not so.

ValuJet 592 tried to land, said the six eyewitnesses. (The fact that their testimonies about continued level flight over the Everglades was omitted from that NTSB Report should be a eye opener; is that why Broderick is gone ? because he waited for that 'domestic crash' ?)

So what’s new in twenty-eight years? Indeed, nothing. But why not ? No records or reports of such smoke-filled flights said Broderick then ! So says the FAA now !

So why aren't there any records Ms. Garvey ? Why, Ms. Garvey have other aviation organizations been able to turn up (pick a number 400 to 1,200) so many ?

Why ? Ms. Garvey, did policy maker Broderick clearly say the FAA had no interest in American-built aircraft in-flight fires or smoke-filled cockpits because they were owned by non American companies.

Is this still FAA policy Ms. Garvey ? Is that FAA regulation quoted in that Werjefelt / Broderick taped conversation still considered not applicable now, as is was then, by Chief Policy maker Broderick Ms. Garvey ?

Does the FAA still expect pilots to not see when the cockpit now fills with dense continuous smoke Ms. Garvey ?

What of the EVAS type technology certified and tested by the FAA back in the early 90s Ms. Garvey, does the FAA still consider that EVAS technology "experimental" as stated by then FAA Flight Standards policy maker Broderick ?

Does his replacement, Mr. McSweeney, now have this same policy ? As FAA administrator Ms. Garvey, is this is your policy decision as well ?

Should we ask Swissair's CEO, Mr. Katz, if he is still waiting for the FAA to mandate that EVAS type technology so his airline may reconsider that 1993 decision not to spend the money. There is money now for the finest gambling systems to be found. How about money for (FAA certifiable) EVAS type technology to enable pilots to see the panel; talk about a gamble of your life.

Let us ask Katz if he is aware of all those "unreliable fire tests" done through the years on those insulation blankets by FAA who now says the "industry has asked them" to use the "more reliable swab tests". (Does the FAA offer any financial aid for recall costs ?)

Ask him if he had seen those FAA test reports (Cahill 1989 and 1995) where explicit warnings were given against resetting C/Bs and to CB limitations in protecting against wire bundle fires.

Ask him if he had seen that "Handbook Bulletin" claimed by the FAA to have been issued to all operators to warn them of 'debris and lint' on wiring bundles to reduce the posibility of bundle fires and smoke ? (but where's the spark originate?) see Annex H

If he has not seen the above, how can he assume the American FAA will be of any help to his flight crews or help protect his expensive aircraft or priceless reputation now tarnished by American business policies ? Want to hope for the best there won't be another sir ?

If he has seen it, then when will the emergency check lists be changed and the crews and maintenance trained; when will EVAS type technology finally be installed?

When will Swissair give the 'house' the best odds possible and stop this kind of gambling ?

Are we talking here about culpably negligent homicide? I do not think that we would need to speculate on this issue, because there is clear evidence proving the case. The definition in terms of law might differ, but to me the background of it is clear enough. No speculation needed here: just use those FAA documents and taped conversations by their own policy makers. In those Werjefelt/Broderick transcripts (if you haven't seen them, see Annex E) the FAA trivialized the problems associated with 'smoke in the cockpit' and showed its scorn for the flying public. Don't look for any of this straight talk in any FAA press releases.

In the Swissair/Werjefelt letter (see below) Swissair turned their backs on this 'long known' problem too. Like ValuJet, Swissair went the money-saving route.

With no information of those wire insulation dangers and cautions to be seen in the Cahill wiring reports and those inadequate fire tests of the insulation blankets by the same FAA Tech Ctr. - crews have little going for them once these fires start. Opening a noisy cockpit window is about it.

What a rotten way to go. The FAA knew about it all along and the NTSB remained silent as well. We have the full story ready for telling comes the next sr111 style crash. See Annexe F & Annex  R

10-22-93 23:55 OTTO RENTSCH

FACSIMILE TRANSMISSION

FROM: OTTO RENTSCH

AVIATION CONSULTANT/SAFETY ADVISOR

FUCHSENBURG 25, 8640 RAPPERSWIL

SWITZERLAND

PHONE/FAX NO: 0041 55 27 62 36

NO. OF PAGES: 2

DATE: October 22, 1993

TO: Bertil Werjefelt, President

VisionSafe Corporation

Fax (808)247-6313

Dear Bertil,

You have asked me to formally answer the question, "Has the record shown that heavy, dense and continuous smoke has caused the loss of otherwise flyable commercial aircraft?" The answer is "Yes". In fact, it is probably relatively common knowledge in the Aviation Safety and Accident Investigation Sectors of the industry, As you know, I recently retired as Head of Safety for Swissair, after working for the company for 40 years. I am now an international aviation consultant on safety matters and am still very much involved in aviation safety activities world-wide.

As we are both well aware, Swissair lost a CV 990 on the 21st February 1970 just outside of Zurich. There were 47 fatalities. This is one of the so called classic accidents, where loss of pilot vision because of dense continuous smoke in the cockpit led to loss of control of the aircraft and the crash. This is well documented in the accident record as well as the recorded conversations between the aircraft and the controllers on the ground. The record clearly shows the aircraft was flyable but ultimately crashed because the pilots couldn't see their flight instruments, which are so critical to maintaining safe flight.

This accident and other cockpit smoke incidents prompted me to encourage Swissair to remedy this safety problem when we learned there was a solution (EVAS). As I recall, many Swissair staff were involved in the testing and evaluation of EVAS, which took about two years. I personally attended several simulator tests where the cockpit was filled with very dense smoke and witnessed our pilots, as well as SAS pilots, accomplishing successful landings, which would have been impossible without EVAS.

I know that it was a decision of Swissair to acquire EVAS for all its aircraft and that SAS was also going to do so, beginning with its 767 fleet. I am also aware that Swissair and SAS have put the actual implementation of EVAS in temporary abeyance. I suspect, to some degree, the recent economic hardships and restructuring of the airline to merge with others may be part of the reason. We were just reminded of the need to correct this serious safety problem as soon as possible. Last week a Swissair MD-81 made an emergency landing at Munich airport due to extreme smoke in the cockpit. The smoke was caused by an electrical cable bundle on fire in the cockpit.

The situation was so serious that the pilots were unable to read the approach chart and the instruments. For example, the speed indication was estimated according to an approximate position of the needle. The Approach Center personnel had to provide assistance to the pilots on frequencies and directions. This level of safety is unquestionably unacceptable. Pilots must be able to see so they can safely control and land their aircraft.

Having talked to the Chief of Accident investigation at the Swiss Department of Transportation, it’s clear that skilful piloting and lots of luck was the only difference between the successful emergency landing versus a catastrophe. A very slight increase in smoke intensity would probably have totally blinded the pilots and might have changed the outcome. (There were 98 passengers and 7 crew on board). The need to ensure pilot vision in such emergencies is very clear. Hopefully the Authorities (and the Airlines) will now act quickly.

Also, if my memory serves me right, the American NTSB issued a safety recommendation

about 10 years ago in connection with a DC-9 (or MD 80/81?) smoke accident in Cincinnatti where there was the same type of situation with severe smoke in the cockpit and the pilots had serious difficulties seeing their instruments. (There was also a similar one in Norway 4 or 5 years ago with a DC-9 or MD-80). In spite of the NTSB recommendation it is obvious that the safety problem still persists.

With further regard to your original question, I am also aware that there have been several other fatal smoke accidents world-wide, many of which the Authorities know and/or suspect were caused by loss of pilot vision. However, to my knowledge, few, if any, are as well documented as the Swissair accident of 1970.

I trust the foregoing answers your question.

Very truly yours

Otto Rentsch

END LETTER

 

EXCERPTS FROM THE TRANSCRIPT OF RADIO CONVERSATION BETWEEN PILOTS AND CONTROLLERS OF THAT 1970 SWISSAIR ACCIDENT, FLIGHT 330 [MENTIONED ABOVE] is at Annex D

$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$

AN INTRODUCTION TO BERT WERJEFELT

This serves to introduce Bert Werjefelt who, several years ago, joined our efforts to expose the problems we had seen with the FAA and the NTSB. These problems included altered reports and inaccurate records. Bert is the CEO of VisionSafe Inc. In the early 90s he had invented a device which assisted the pilots and provided a clear path of vision to the critical flight instruments and the outside world when faced with dense continuous smoke in the cockpit. With his product, he applied and met the FAA’s stringent requirements for certification. Instead of open arms, his certificated product was soon bad-mouthed in the industry by the very same FAA. The FAA had realized that such a product undermined the long-held FAA position that dense continuous in-flight smoke events were virtually non existent and had claimed no lives on US domestic carriers. This was untrue and contrary to many official reports produced by Bert that focused chiefly on overseas non-domestic carriers using US certificated equipment. The non-domestic carrier events clearly demonstrated this problem of the pilots’ inability to see and was hardly a phenomenon of just these carriers.

Simply, Bert's product was necessitated, in part, by the result of fires from the wire and sound blanket insulation materials that now are seen as far more flammable than previously acknowledged. His early battle with the FAA produced many hundreds of FAA documents which are relevant to the ValuJet 592, TWA 800 and Swissair 111 tragedies which were yet to come. They fill in many blanks of what the FAA knew and when did they know it, but more importantly, they give a clearer picture of the FAA culture and agendas contrary to the FAA's public face and claims of 'Safety Is Number One'.

Attached (as Annex E) are two transcripts of Bert's phone calls to the (then) FAA Deputy Administrator, Anthony Broderick, and are produced here in an e-mail format. Copies of the original formats and any of the referenced documents here are available.

These transcripts are instructive, informative and shocking to the first-time reader. The 12 in-flight examples of 'dense continuous smoke' in the cockpit events given by Bert were aboard overseas carriers. The FAA would have you believe that overseas events on US built and certified equipment is irrelevant to FAA rule making; in fact, it’s illegal (under the FAR) for the FAA to ignore them.

In this pre-ValuJet FAA rhetoric heard here, the FAA claims that lack of rule making was because "no domestic carrier" had lost a life due to such dense smoke. That is now measured against the loss of flight 592 and, of course, flight 111. The NTSB’s ValuJet 592 Final Report’s exclusive focus on the oxygen canisters as the initiating event is troublesome. That report was loaded with undocumented opinions, conjecture, alteration and deleting of contrary witness reports, omissions of contrary facts, adoption of incomplete data as fact, etc. It appears that ValuJet may have been a horrific rebuttal to the FAA’s long standing denials to the dangers of in-flight ‘dense continuous smoke’ problems and compounded all the more by the now understood FAA’s long-standing awareness to wire and acoustical sound proofing insulation flammability troubles.

PATTERNS OF DECEPTION

We now know that the FAA's limited 60 degree wire flammability test saw some samples exceed the FAA's own standards for smoke production. Unfortunately, aircraft wire bundles also run straight up and down (90 degrees) and, of course, a fire travels that way much more quickly. (See Cahill’s report DOT/FAA/CT-89/29).

In these transcripts, the FAA claimed then, and claims now, that they had ‘no reports' as their rationale for lack of FAA actions to the dangers of in-flight fires. That claimed lack of reports became the reasons for the lack of rule-making to provide the means to survive such 'dense continuous smoke' events where the pilots cannot see vital instruments, cannot see out their windows and are essentially blind. Claims of 'no records' are now measured against the increasing numbers of just such events ‘found’ since flight sr111. Contrary to that, 264 such events were testified to by FAA's McSweeny in that November 1993 Senate Aviation hearing as the FAA then sought to downplay Bert's testimony (to the need for the FAA to follow its own rule-making to provide solutions so that pilots need not be insolubly blinded).

Bert addressed but a few of the possible ignition sources then, the FAA offered none. We now know that the FAA's 'Bunsen burner test' is "unreliable" compared to the industry sought after ‘swab test’ and that many types of insulation blankets found throughout the world’s fleet of about 12,000 airliners are far more flammable than previously thought. (See Cahill’s report #DOT/FAA/AR-97/58). In this report alone, five on-the-ground aircraft fires are cataloged. Had they been in-flight fires, injuries and deaths would obviously have occurred. Although important enough to find their way into this report, but in a continuing pattern of hiding such serious events, none of these events can be found in the usual FAA/ NTSB Internet database.

We now know of that latter Tech Center report, plus Cahill's two other reports (DOT/FAA/CT-88/4 and DOT/FAA/CT-TN94/55). These reports described the hazards; of wire insulation, resetting of circuit breakers, inability of circuit breakers to protect against anything more than Direct Shorts, and the clear definition that this is an "Electrical" problem (versus a "Mechanical") weren't included in her Tech Center Database Library Catalog until our complaint early this year. Again, even though important enough to find their way into this report, none of the three illustrative in-flight fires in the 95 report can be found in the usual FAA/NTSB Internet database.

We now know of the twisted trail of FAA’s FOIA responses that finally produced those three reports. Various FAA Regionals (including the originating Regional) either denied or claimed ignorance of one or more of the other associated reports.

Now, hundreds of such events have been found and the accuracy of these databases has become an issue. Administrator Garvey has also noted the incompleteness of these databases and their diminished value to identify the scope of these in-flight events. In the transcripts here, and in recent times now, the FAA still continues to point to their own databases as evidence to trivialize the scope of these ‘smoke in the cockpit’ problems. Worst yet, you find no wording or attention to the wire and thermal acoustic insulation flammability testing troubles. (See DOT/FAA/AR-97/58, "Evaluation of Fire Test Methods for Aircraft Thermal Acoustic Insulation" by D. Blake).

By no means last, it appears the omissions of data to these flammability problems is certainly a pattern. At this point, the FAA’s claims to have issued a ‘Handbook Bulletin’ drawing attention to wire bundle fires involving lint and debris but this also cannot be found amongst 440 other such ‘Bulletins’. This Bulletin was to draw attention to unexplained wire bundle fires but made no connections with the three Cahill reports describing the electrical initiating event.

There’s more, but for now lets step back to 1992/3 and listen to what the FAA had to say (at Annex E). The 1993 transcript is presented first because it offers extensive background narrative. Second, the 1992 transcript demonstrates the FAA’s consistency and patterns of denials. Lastly, for those of you who have never seen it, my list of almost three dozen such in-flight emergencies taken from the very limited databases is at Annex F. The sources are noted. These comprise but 11% of the lowest number of 264 testified to by FAA in that 1993 Senate Hearing. More recent disclosures range far higher.

TRANSCRIPT OF PHONE CONVERSATION WITH DEPUTY FAA ADMINISTRATOR ANTHONY BRODERICK CONCERNING HIS OBSTRUCTION OF THE ENFORCEMENT OF CRITICAL AVIATION SAFETY REGULATIONS. JANUARY 26, 1993, pg 5,11, 12, &13

The following transcript (Annex E) is one of many recorded conversations between Bert Werjefelt, President of Vision Safe Corp, Hawaii and FAA officials. In order to put the conversation in perspective, included herewith is some brief background information (pages 1- 4) and also some explanatory commentary in the course of the conversation (by Werjefelt).

SUMMING UP: In spite of explicit and well known legal requirements to eliminate "unsafe conditions" and full knowledge of numerous accidents and serious incidents of unsafe conditions relating to loss of pilot vision because of "hazardous quantities" of "continuous" smoke in the cockpit, where many hundreds of lives have been lost, in clear defiance of the law, Anthony Broderick, the Deputy FAA Administrator, makes it shockingly clear in the following conversation that he does not intend to enforce the existing safety regulations to eliminate this unsafe condition until after! there has been yet another smoke accident – with a US airline. Boeing has told the Wall Street Journal, that they alone have lost seven jets where smoke in the cockpit was a suspected cause. Our information about Mr. Broderick is made public because we consider Mr. Broderick’s actions on the unsafe conditions relating to smoke in the cockpit a shocking abuse of the public trust and in clear violation of his duties under the Federal Aviation Act. We are not the only ones with complaints about Mr. Broderick. It is now well known that Mr. Broderick is also under criminal investigation by the Deputy Inspector General for obstruction, or interfering with an investigation, concerning enforcement of the safety regulations relating to "bogus parts". We believe the "smoke in the cockpit" issue closely parallels and may strongly reinforce the Inspector General’s current investigation of Mr. Broderick. [Note: Broderick was dismissed pursuant to the revelations of the Valujet crash investigation]

EVIDENCE OF UNSAFE CONDITIONS: Following (see Annex G) is a list of some smoke related accidents which clearly delineate the safety problem which the FAA is required to eliminate . The law requires that, based on all but one of these accidents (02 JUL ‘86, this foreign aircraft was not certified by the FAA), that the FAA take action to eliminate the unsafe condition, where pilots cannot see the flight path or the vital instruments to safely control and land the plane, because the inherent design/operation of the smoke evacuation systems do not function sufficiently to remove the smoke from their critical field of vision.

BACKGROUND: In the early eighties I (Werjefelt) developed a new type of closed circuit emergency breathing equipment (long duration and very compact and light-weight smoke hood) which was primarily intended for airline passenger use to protect against smoke and toxic fumes during inflight smoke and fire emergencies. - There had been numerous tragic accidents where many hundreds of people had been asphyxiated.. This technology, which was later licensed to one of the Fortune top ten companies is now in use, but only for crew use, on approximately 80% of the US airliners and 50% world wide.

I testified in several Senate and House Hearings on airliner health and safety matters during the 80's. In the course of these events I had occasion to discuss these serious safety matters with the then director of Safety of the FAA, Jack Harrison.

Harrison made it dear that he wanted us to "get off the FAA’s back about getting smoke protection on board the planes for passengers, because it won’t happen,.." When questioned why, loosely quoted, he responded that "what good is it to protect the passengers from smoke and toxic fumes when the pilots can’t even see to land the plane because of all the smoke? He went on to say that there is a regulation that requires pilots to be able to see when they have smoke emergencies ( FAR 25.831 (d), which The Airline Pilots Association petitioned the government to establish ), but, in spite of the regulation, neither the FAA nor any of the major airframe manufacturers had been able to solve this safety problem, to meet the requirements of the safety regulation for serious smoke emergencies. - They could only deal with very small amounts of smoke which as he made very clear to me, is not what kills people or blinds the pilots. It’s the serious emergencies where the smoke can’t be stopped that is the real problem, he said. He also pointed out that there had been many smoke in the cockpit accidents. Boeing later told us they had been working to solve the problem for the last forty years and subsequently they also told the Wall Street Journal that they (Boeing) alone had lost seven jets where smoke in the cockpit was a suspected cause. - The Boeing statement coincides with the accident record.

He (Harrison) told me that if I could solve this safety problem so pilots could see then we could seriously discuss the matter of passenger smoke protection. I accepted his reasoning although I didn’t fully agree with him, since the pilots have respiratory protection and the same toxic fumes they are protected from, are equally toxic to the passengers. I also quietly accepted the challenge to find a way to ensure pilots would be able to see to safely control and land the plane during serious smoke emergencies.

To make a long story short: After several years of research and development and testing I came up with a technical solution, which positively evacuates any smoke from the pilots’ critical field of vision so the pilots can see the flight path and vital instruments to safely control and land the plane. This has been fully FAA certified since 1990. The equipment is very small and weighs only 5 lbs. and does not require any modification to the aircraft. It’s as simple to use as a fire extinguisher. Scores of pilots from many airlines (as well as private companies) have used the equipment in simulated cockpit smoke with less than one minute of training. Smoke has been so thick you could not even see the hand in front of your face. Yet, every time when using this equipment, pilots have been able to land (the simulator). They have also verified that without this equipment, they crashed every time.

Subsequently, FAA in Washington was informed about the new FAA certified technology and we asked them to enforce the relevant safety regulation. To our complete astonishment, the FAA refused, claiming it was no longer a safety problem and that the existing systems were adequate. They also told us, and others who inquired, that our equipment was only experimental, when in fact it was fully FAA certified. (It had taken us several years to accomplish this.) The FAA even tried to rescind the FAA certification, but were not successful.

There is much more to the story about all the acrimony and the- - flagrant malfeasance by FAA officials. We have file cabinets full attesting to unbelievable stonewalling, even to the point where the FAA has literally re-written accident reports in order to try to cover up the unsafe conditions so they would not have to act to enforce the existing safety regulation.

In retrospect one must seriously question whether Harrison, FAA’s Director of Safety, was hoping to send me on a wild goose chase to solve a problem that appeared to them to be insoluble (they had been working on it for decades). By so doing he would have me 'off the FAA’s back' about passenger smoke protection. Or, possibly, he was genuinely trying to get rid of the unsafe conditions, so pilots could see and passengers would have respiratory protection and not have to be asphyxiated. In any event, the FAA is now faced with both issues. - Or, stonewalling the entire matter, which is what they have been doing.

Providing for pilot vision is simple and inexpensive in terms of airline economics (about one cent -per ticketed passenger). But, you can’t just do that and have the pilots land a plane full of "asphyxiated" passengers! So, they must also address passenger respiratory protection which is also relatively inexpensive - (a few cents per ticketed passenger) and a relatively simple task in terms of educating the public in how to use the equipment. But above all, the way I perceive it, is that they (FAA. and the Airlines) are fearful of telling or reminding the consumer (when they go through their safety demonstration) that there may be smoke emergencies, when so many airline passengers are already white knuckle fliers.

Nevertheless, the following conversation (see Annex E) clearly shows that Mr. Broderick, the Deputy FAA Administrator is flagrantly violating the law and stonewalling the enforcement of the existing safety regulations, to the detriment of public safety. He makes it perfectly dear that he has no intention of enforcing the existing safety regulation to ensure pilots can see to safely control and land the aircraft during serious smoke emergencies, until after there has been yet another tragic disaster claiming American lives – on a US airline! We believe any pilot or passenger, who is knowledgeable about the facts would be left in shocked disbelief after reviewing the conversation with Mr. Broderick. We could not believe what we were hearing - However there is no doubt whatsoever about Mr. Broderick’s totally irresponsible behavior because, this is not the only conversation we have had with Mr. Broderick et al which confirms this unbelievable hidden agenda and abuse of the public. Now go to Annex E for the phone transcripts.

 

Summary

The Swissair MD11 accident has opened a lot of eyes about many different aspects of coping with fire in the cockpit. Of course the investigation is as yet incomplete but sufficient is known for us to make the following reasonable assumptions:

a. The pilots were not sufficiently alarmed at the outset for them to try and rush to a landing. In part this is because of a suspension of belief ("This can’t be happening to me"). True fear (and its urgent motivation) is lacking initially because large electrical fires always start off as smaller, seemingly innocuous ones. They get to be bigger catastrophic life-threatening fires because, under the current checklist philosophies (and switchology), the power never comes off the wires. This lack of alarm can also be attributed to a "society of success" attitude that prevails in simulator training. That optimistic doctrine of positivism would have it that, as long as a crew reacts as per "the book" with the correct CRM approach, all will come right in the end. Unfortunately real life is not like that. The current protractedly optimistic trouble-shooting smoke checklist allows an electrical fire to develop (in real life) simply because the power doesn’t come off the wires. In the simulator it’s not realistically portrayed as such a potentially cataclysmic circumstance so pilots are duped into a mindset that has the smoke-in-the-cockpit drill aligned with the straightforward exercises such as an engine fire or turbine failure. In a "kaptonized" aircraft the attitudinally correct approach should be that "all may well be lost if the power doesn’t come off the wires - pronto". The Canadian TSB has confirmed (on 11 Jan 99) that arcing was found on sr111 cockpit Kapton wiring.

b. The MD11 (and probably other airliners) sets the "air-conditioning smoke" checklist first (possibly because it’s not going to take power off the busses and disrupt meal service). The fact remains that this is a lengthy checklist and the electrical fire is still being permitted to develop unchecked. The aircon checklist asks four times: "has the smoke begun to reduce" and the pilots must wait to consult the cabin attendants about this. At the end of this checklist the conclusion is that the smoke is not of aircon origin and says that the "Smoke & Fumes of Unknown Origin" checklist should be started. Obviously these two checklists are in the wrong order because aircon smoke (from oil-contaminated bleed air) is just not going to kill (or incapacitate) you – but interim developing electrical system fires will.

c. The MD11 Smoke/Elec/Air Switch has four positions that de-select (and then re-select) a third of the aircon and gens and busses at a time. The checklist calls for a pregnant pause between selections in order to check whether the benign configuration has been yet reached. There is no mention of what to do if a benign configuration is never found. During this checklist control must pass between the pilots as one the or other will lose their flight instruments. The radios will also lose power and the pilots must remember (but probably won’t) to switch their current comms frequency to each successive "live set". The DFDR and CVR are also powered down at certain stages. It may be the case that the battery (and GEN reset ability) is insufficiently protected from a dead short under the MD11’s electrical system. An induced fault in one or both of the epi-centric bus-tie sensing relay switches can leave the backup instrumentation vulnerable to the original electrical fault. At some stage during the checklist the #2 tail-engine is liable to flame-out because of power coming off its pumps (and being too high-set to gravity feed). This would tend to (audibly and visually) Xmas-tree the cockpit and distract the pilots (as well as robbing the system of one of two Generators on line). An electrical system short may then be sufficient to trip the remaining generator and leave the battery liable to overload (and/or Batt CB trip).

d. In night or IMC conditions the critical backup attitude indicator is mounted centrally (low and forward) on the centre console – not really an ideal positioning for either pilot’s scan.

e. Emergency flood-lighting is still aircraft battery-powered and vulnerable to a total electrics failure. A fore-head-mounted (atop full-face smoke-mask) focusable light with an integral battery would be preferred to cockpit flood lights that tend to reflect off flight-deck screens and windows.

f. A third man (the old Flight-Engineer) with good systems knowledge and a role in the checklist would have been invaluable. In a two-man crew there is evident overloading (see Annex U). You need a third man to be able to send a technical flightcrew-member down the back on a portable oxy set.(to check and report or fight fire). The MD11 checklist prohibits a crew-member from leaving his seat (and oxy set). see annex L and Annex M plus http://www.geocities.com/Eureka/Concourse/7349/landings3.html  

g. Halon or BCF hand-held fire-extinguishers probably wouldn’t make a lot of difference if an electrical fire was still powered. But the question must still be asked: "who (anyway) has the time to use it in a two man-crew that is locked to their seats by the umbilical of their oxy systems?". A flight-deck nitrogen inerting system may well be worthwhile considering (see Annex M).

h. The very unwise plumbing of the Swissair Inflight Entertainment System (IFE) into one of the cockpit busses (AC2), vice an ancillary cabin bus, was obviously done because the high current-drawing IFE would otherwise have necessitated a complete revamp of the electrical distribution system (i.e. creation of a Cabin 2 bus). If that had been the case, the Smk&Fumes Cklist would then have killed any IFE-stoked fire at step one (Cabin P/B OFF).

i. The FAA’s obligation (under the FAR) to resolve the dense continuous smoke in the cockpit problem continues to be studiously ignored. The
EVAS equipment is one way to go (Annex E and http://www.raytheon.com/rac/rapid/evas.htm   ). The Impaired Vision Flight Safety Device (incorporating a full-face smoke-mask) proposal at Annex T is another. Kapton incidents have happened since sr111, luckily with no loss of life….but it is only a matter of time (Annex V and Annex F).

j. Annexes S & M contain sr111 technical commentary and proposed solutions. In particular it is recommended that current Smoke & Fumes checklists be examined closely in light of what is known about Kapton wiring induced electrical system failures and fires. Maintaining power on busses whilst trouble-shooting is simply not a wise move. In fact it is foolishly unsafe to do so. It may not be possible to eliminate Kapton from modern airliners for many years, yet there may be a cheap and practical way to bypass the catastrophic effects of a large-scale flash-over in a (continuously powered) failed Kapton wiring bundle. Annex S and the following Internet site http://www.geocities.com/Eureka/Concourse/7349/virgin.html     discusses the advantages of a proposed modification that has been termed "the Virgin Bus". It is designedly a TKT wired add-on that would give crews a readily selectable fallback position; a stand-alone "get-you-home" flight essential bus with minimal features that would avoid the undeniable gamble of the present trouble-shooting checklist. Its main feature is that "everybody lives" and this should become a fine selling point for a public that may soon be looking in askance at an airline industry that has suffered its next sr111. The following Internet sites are also dedicated to constructive debate on aircraft wiring and sr111 in particular: http://members.aol.com/papcecst 
http://www.geocities.com/Eureka/Concourse/7349/index.html  
http://www.aviationtoday.com/reports/wiring.htm    

Conclusion
Neither Airline X’s safety reputation nor its superior maintenance can protect it against the depredations of flawed wiring insulation. A slavish adherence to the long-held doctrine that FAA’s Bulletins and Directives are sacrosanct would not be wise for Airline X. The US FAA and the manufacturer are set on a path that has been decreed by their vested interests. These interests are demonstrably contrary to the safety of the travelling public. As long as no US airline is involved in a fatal Kapton accident the FAA policy of denial will run its course. As you can see from Annex E, foreign airline accidents are of no consequence in determining FAA agendas. Military attitudes (in banning Kapton) are also claimed to be irrelevant. The lessons of the post-Valujet shake-out of the FAA hierarchy have been set aside and FAA loyalties have been hopelessly compromised. Airline X’s best interests must be determined by itself in light of both what Airline X now knows and the public’s forthcoming knowledge of that. Inaction is not an option.

IASA (Aart van der Wal and John Sampson)

 

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