From correspondents in Halifax, Nova Scotia

Pilot Zimmerman (rt) with Father

March 28, 2003

A FIRE likely caused by an electrical spark crept undetected along the insulation of Swissair Flight 111, giving the pilots no chance to save the 229 people on board, the final report by investigators concluded today.

Canada's Transportation Safety Board ended its largest investigation ever after four years of probing one of the worst tragedies in aviation history.

The probe cost more than $US30 million ($50.26 million) but was unable to declare unequivocally what caused the fire that brought down the MD-11 airliner off the coast of Nova Scotia in 1998.

The 338-page report focused on the in-flight entertainment system aboard the McDonnell-Douglas aircraft, saying a problem with wiring to power the system went undetected and the spark "most likely" started there.

It said the US Federal Aviation Administration's certifying system failed to ensure that the entertainment system was designed and installed properly for the MD-11.

Swissair Flight 111 plunged into the Atlantic Ocean off the Nova Scotia coast while en route from New York to Geneva on September 2, 1998. Pilots reported smoke in the cockpit 53 minutes into the trip, and the electrical systems began failing 13 minutes later.

Since the crash, Swissair has gone out of business following the September 11, 2001, terrorist attacks that crippled the airline industry.

The report included nine safety recommendations involving testing for insulation materials and electrical systems, and improving the flight cockpit and data recording systems.

Those recommendations follow 14 previously made by safety board investigators that led to flammable insulation material being removed from aircraft and improved fire reaction measures for pilots.

"This has been the largest, most complex aviation investigation the TSB has ever undertaken," said safety board chairman Camille Theriault.

"The efforts of thousands of hardworking people from various countries, industries and regulatory authorities have culminated in a comprehensive report that has changed the face of aviation safety."

The report provided a clinical and sobering account of the tragedy, telling how a spark in the wiring of the in-flight entertainment system probably started a fire that slowly burned its way through insulation above the cockpit.

"It was determined that the fire most likely started from an electrical arcing event that occurred above the ceiling on the right side of the cockpit," the executive summary said.

It offered no specific reason for what caused the spark, but the recommendations included additional measures to certify additional systems like the in-flight entertainment system and raise industry standards for resetting circuit breakers.

Gerry Einarsson, a former Canadian government transport engineer, recently said the entertainment system - which allows passengers to view videos and play computer games - required excessive amounts of power to operate that resulted in higher cabin temperatures.

The report noted a check of 15 other Swissair MD-11s showed the wiring for the entertainment system was installed differently on four of them.

The overall result, it said, was that the project management structure of the FAA certification of the entertainment system "did not ensure that all the required elements were in place to design, install and certify a system that would be compatible with the MD-11 type certificate".

A lack of smoke or fire detection and suppression devices, which were not required at the time, left the crew with few resources, the report said. That delay gave the pilots no chance to safely execute an emergency landing.

"We have concluded that, even if the pilots could have foreseen the eventual deterioration due to the fire - because of the rapid progression of the fire, they would not have been able to complete a safe landing," said prepared text of comments by Vic Gerden, the chief investigator.

Investigators used 2 million pieces of recovered wreckage, some as small as a dollar coin, to partially reconstruct the MD-11 jetliner.

Three years ago, the Canadian safety board recommended that airlines do a better job of training and equipping crews to detect and fight fires on planes.

An earlier recommendation by investigators noted safety problems with the plane's insulation blankets, which have been suspected of spreading fire. The FAA in the United States responded by requiring removal of the insulation blankets from all US-registered MD-11 aircraft.

In March 2002, a US federal judge dismissed claims for punitive damages for families of victims of the Swissair crash.

The Associated Press

Investigators implicate entertainment system wiring in Swissair crash

Canada Press

Canadian Press

Thursday, March 27, 2003

HALIFAX (CP) - Wiring that fed a controversial entertainment system aboard

Swissair Flight 111 likely contributed to a fire that brought the plane down

off Nova Scotia in 1998, investigators said Thursday.

The Transportation Safety Board didn't identify the exact source of a fire

that led to a massive electrical failure aboard the MD-11 jetliner, but

concluded it was linked to the system.

In a 337-page report, the agency said the fire started when wire arced above

the ceiling on the right side of the cockpit. The arcing - a phenomenon in

which a wire's coating is corroded and can lead to sparking - ignited a

flammable insulation covering, allowing the fire to race through the plane's

wiring system.

"Investigators believe that this arcing event on the entertainment system

wire was associated with the initial arcing event," the agency said in a release.

"However, investigators could not pinpoint this as the lead event."

The board said it had recovered 20 pieces of wire from the shattered remains

of the plane that showed melted copper, indicative of arcing damage.

Vic Gerden, the agency's lead investigator, said this was likely not the

only wire involved in the arcing.

"We strongly suspect that at least one other wire was involved, either an

aircraft wire or another entertainment system wire," he said in a statement.

Investigators also determined the pilots acted appropriately in not trying

to land the plane immediately, something critics have argued would have

saved some or all of the 229 people who died in the crash.

The pilots spent valuable minutes trying to identify the source of the fire

after smelling smoke 53 minutes into the flight. They diverted away from the

Halifax airport to dump fuel over the ocean after having a near full load

since leaving New York for the transatlantic trip.

The board did a theoretical "descent profile" and found the pilots would

"not have been able to complete a safe landing in Halifax, even if they had

undertaken to do so at the time of the PAN PAN urgency radio communication,"

the report says.

The agency, which has spent $60 million and 4 years examining millions of

pieces of wreckage in the case, issued nine new recommendations. Two address

testing and flammability standards of thermal acoustic insulation materials.

It also recommended improved certification standards for planes' add-on

systems, such as the entertainment system.

Four recommendations propose improvements to how information from the flight

data and cockpit voice recorders is captured and stored.

Some aviation experts believe the entertainment unit is key to the fire.

Critics have said the system was so hastily installed on the MD-11 that the

proper inspections weren't done to ensure it could operate safely in the air.

One avionics expert called it a "power-hungry monster" that demanded an

excessive amount of energy. Critics have blamed the U.S. Federal Aviation

Administration in part for allegedly shirking its duties in certifying the

system - something they said the safety board should have addressed in its report.

The system, which allowed passengers to gamble, play video games and watch

movies, was found on test flights to raise cabin temperatures and cause hard

drives in the seats to fail.

The board has released several recommendations and advisories over the

course of the investigation. They have included calls for more stringent

testing of electrical wiring in aircraft, inspection of cockpit wiring of

all MD-11s and independent power sources for flight recorders.

In 1999, after investigators determined that metallized Mylar insulation on

the plane helped to spread the fire, the FAA ordered U.S.-registered

airplanes to replace the material within four years.

"It is important to emphasize here that without the presence of this and

other flammable material, this accident would not have happened," Gerden said.


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