Transport Canada Response to TSB Report on SR-111

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Transport Canada

News release

No. H024/03
For release March 27, 2003


OTTAWA - Transport Minister David Collenette today provided an initial response to the Transportation Safety Board’s final report on the crash of Swissair Flight 111 following an on-board fire off the coast of Nova Scotia on September 2, 1998.

“I would first like to commend the Transportation Safety Board for its thorough and exhaustive investigation into this tragic accident - an investigation of unprecedented magnitude in Canadian history.

“The issues raised in the Transportation Safety Board’s final report are detailed and complex. The report culminates four-and-a-half years of painstaking work by Canadian investigators that will significantly enhance international aviation safety. The board’s interim reports on the Swissair accident have already led to worldwide improvements in aviation safety,” said Mr. Collenette.

There are no MD-11 aircraft - the type of aircraft involved in the Swissair accident - operated by Canadian carriers. The board’s recommendations are directed to world aviation regulatory authorities. As a result, this accident will require international cooperation and resolve to implement the recommended safety actions. Transport Canada will assume a leadership role and bring the board’s work directly to the attention of its international partners, including the U.S. Federal Aviation Administration and the Joint European Aviation Authorities, through various international safety working groups and committees.

“I have written to my counterpart in the United States, Transportation Secretary Norman Mineta, to encourage the United States to adopt the board’s recommendations. The MD-11 aircraft involved in the Swissair accident was certified in the United States and, as such, the U.S. Federal Aviation Administration will play a key role in implementing the board’s recommendations,” said Mr. Collenette.

“I have also written my counterpart in France, M. Gilles de Robien, Minister for Capital Works, Transportation, Housing, Tourism and Maritime Affairs and Mr. Klaus Koplin, Secretary General Joint Aviation Authorities, to engage them and other international partners in addressing the safety issues raised in the report.”

Transport Canada has already taken action on the board’s recommendations and has assessed the Canadian fleet to confirm that no Canadian registered aircraft were using metalized Mylar covered insulation blankets (MPET), which were identified by the board as significant contributors to the spread of fire on this aircraft. As a further precautionary measure, the department has issued an airworthiness notice to the Canadian aviation industry, including manufacturing and maintenance organizations, design organizations and operators, to reinforce that MPET not be used.

In the course of its investigation, the board has broken new scientific ground to help identify the potential causes of this complex accident and developed new testing methods that will become standard practice for aircraft safety and design.

Transport Canada accepts the new scientific flammability test recommended by the Transportation Safety Board and is proposing new rules for flammability tests that will govern Canadian industry. These new rules will exceed what is recommended by the board.

“My department will provide a formal response to the board’s report within 90 days and looks forward to working closely with the Transportation Safety Board, the U.S. Federal Aviation Administration and our other domestic and international partners and stakeholders to achieve the goals and safety objectives brought forward in this final report,” added Mr. Collenette.

A backgrounder outlining Transport Canada’s comprehensive approach to aircraft fire safety is attached, and a detailed document outlining Transport Canada’s initial response to the report is available at


Anthony Polci
Director of Communications
Office of the Minister, Ottawa
(613) 991-0700

Transport Canada is online at Subscribe to news releases and speeches at and keep up-to-date on the latest from Transport Canada.

This news release may be made available in alternative formats for persons with visual disabilities.



Canada has one of the safest air transportation systems in the world. This system operates on the principle that, both in the air and on the ground, safety is a shared responsibility between all parties involved - regulators, manufacturers and operators.

Aircraft fire safety is a key aspect of Transport Canada’s safety responsibilities. Specifically, it is responsible for the development, implementation and enforcement of safety standards and regulations under the Canadian Aviation Regulations.

Fire safety on-board aircraft involves complex issues that require international cooperation between regulators, manufacturers and operators. Transport Canada works actively with partner authorities, particularly the U.S. Federal Aviation Administration (FAA) and the European Joint Aviation Authorities, along with industry at home and from around the world, both directly and within recognized international working groups and committees, to address pertinent issues. Examples of such groups include the FAA’s International Aircraft Materials Fire Test Working Group and International Aircraft Systems Fire Protection Working Group, as well as the Aging Transport System Rulemaking Advisory Committee.

Canadian design certification standards include several measures to minimize the likelihood of on-board fires and to counteract fires in areas that have been identified to be most vulnerable, such as engines, cargo compartments and lavatories. These measures are based on a thorough assessment of fire risks and conditions. The standards require the provision of fire/smoke detection systems and suppression/extinguishing systems, the isolation of ignition sources and the means to prevent, through design, the accumulation of flammable fluids and vapors.

Transport Canada’s progress on significant fire safety improvements has focused on the following areas:

  • stringent flammability and fire resistance standards for seat cushions and cabin interior materials to extend evacuation time, for escape slides to augment their resistance to radiant heat from fires and for cargo compartments to contain possible fires;
  • cabin floor emergency lighting systems to provide guidance to exits in smoke conditions;
  • improved on-board fire fighting equipment to enhance in-flight fire fighting; and
  • fire detection and extinguishing and suppression systems for lavatories and for cargo compartments that are not accessible in flight.

Transport Canada is also working with other regulatory authorities to improve standards for other materials and technologies. This work includes:

  • developing improved flammability criteria for hidden materials such as wiring - expected to be completed this year - to reduce their propensity for ignition and flame propagation;
  • investigating new technologies and systems which can mitigate the risk of ignition, such as arc-fault interrupters;
  • reviewing fire risks and conditions in various hidden areas and investigating means to provide enhanced detection and suppression in such areas; and
  • developing advanced fire-resistant materials.

Transport Canada is committed to taking appropriate action to protect the travelling public and will continue to work with the international community to achieve a consensus on air transportation safety that reflects the concerns of the department and the Transportation Safety Board.

March 2003



New Recommendations 
Regulatory authorities quantify and mitigate the risks associated with in-service thermal acoustic insulating materials that have failed the Radiant Panel Test 

Regulatory authorities develop a test regime that will effectively prevent the certification of any thermal acoustic insulation material that, based on realistic ignition scenarios, would sustain or propagate fires. Interim Recommendation 

On an urgent basis, regulatory authorities validate all thermal acoustical insulation materials in use, or intended for use, in applicable aircraft, against test criteria that are more rigorous than those in Appendix F of FAR 25.853, and similar regulations, and that are representative of actual in-service system performance.




TC accepts that the Radiant Panel Test (RPT) is a significant step forward to improving safety over previous testing methods and will implement the RPT as the new standard for setting flammability criteria for thermal acoustic insulation materials as soon as possible. The RPT uses realistic ignition sources and has been validated against full-scale tests.

TC actively participated in developing the RPT and has now drafted Notices of Proposed Amendments (NPAs) that are scheduled to proceed through the formal Canadian regulatory process in the Fall of 2003. These proposed NPAs go beyond the scope of the TSB recommendation by incorporating criteria for thermal acoustic insulation to act as a barrier to the penetration of external fires into the cabin (burn through test). 

TC is also working with the FAA, through the auspices of the International Aircraft Materials Fire Test Working Group (IAMFTWG), to refine the RPT procedure criteria to include various elements such as hook and loop, tapes, adhesives, etc. 

TC has also proposed that the IAMFTWG be tasked to review of other materials identified by the TSB as a concern. 

The results of these activities will allow TC and other regulatory authorities to quantify and develop the necessary mitigation to address the risks associated with in-service insulating materials. 

Through our active participation in various working groups, both domestically and internationally, TC believes that the IAMFTWG is the best forum to address these issues effectively. The IAMFTWG consists of over one hundred internationally recognized specialists in the field, including TC representation.

Interim Recommendation 
Regulatory authorities confirm that sufficient action is being taken, on an urgent basis, to reduce or eliminate the risk associated with the use of metallized PET-covered insulation blankets in aircraft. 





TC immediately assessed the Canadian fleet to confirm that no Canadian registered aircraft had used metallized Mylar (MPET) covered insulation blankets. This assessment included targeted physical reviews of insulation materials by means of visual inspections by TC inspectors. 

Moreover, as the authority responsible for the certification of Bombardier products, TC also confirmed that Bombardier is not using MPET type products in their aircraft manufacture or design. 

During the period 2000-2002, worldwide regulatory authorities issued airworthiness directives (ADs) that requires the removal of MPET from affected aircraft. 

As further precautionary measure, TC has issued an airworthiness notice to the Canadian industry including manufacturing and maintenance organizations, design organizations and operators to reinforce that MPET not be used.


New Recommendation 
Regulatory authorities take action to ensure the accurate and consistent interpretation of the regulations governing material flammability requirement for aircraft materials so as to prevent the use of any material with inappropriate flammability characteristics 

Interim Recommendation 
For the pressurized portion of the aircraft, flammability standards for material used in the manufacture of any aeronautical product be revised, based on realistic ignition scenarios, to prevent the use of any material that sustains or propagates fire.

TC has proposed to the FAA that the IAMFTWG be tasked to review specific materials identified by the TSB as a concern, such as end caps. 

In addition, TC is continuing to work in the IAMFTWG on the development of test methods for other materials in hidden areas. Significant progress is being made. For example, test criteria for wiring (single, in bundles, including clamps etc.) are expected to be completed in 2003 and the development of these test criteria into standards will commence shortly thereafter. Other work on materials such as clamps, ducting, foams, and seals is progressing.

These testing standards will take into consideration realistic ignition scenarios. 

The current IAMFTWG work to define suitable testing standards will become the basis for implementing improved standards and guidance material.

Through our active participation in various working groups, both domestically and internationally, TC believes that the IAMFTWG is the best forum to address these issues effectively. The IAMFTWG consists of over one hundred internationally recognized specialists in the field, including TC representation.

Safety Concern Contamination Effects











TC is concerned about any negative impact on safety from contamination of insulation materials and has taken action. 

TC has participated, with the JAA and the FAA, in the development of an Enhanced Zonal Analysis Program (EZAP). EZAP adds inspection and maintenance actions for aircraft wiring and the wiring’s immediate environment to determine the necessity to inspect and clean the zone of contaminants or combustible material found in the zone. EZAP will require initial and on-going inspection and cleaning of aircraft zones with wiring. EZAP has been implemented for new aircraft and an implementation plan is being developed for in-service aircraft. 

On November 8, 2001, TC issued instructions to its maintenance inspectors to ensure that maintenance schedules for large transport category airplanes include approved procedures for the inspection of the thermal acoustic insulation during heavy maintenance checks to detect any contamination. 

TC is completing a formal risk assessment related to another on-board fire scenario that addresses the effects of contamination. The risk assessment team includes representatives from TC, the FAA, the TSB, the NTSB and the aircraft manufacturer. This assessment will establish the appropriate mitigation measures.


New Recommendation 
Regulatory authorities require that every system installed through the STC process, undergo a level of quantitative analysis to ensure that it is properly integrated with aircraft type-certified procedures, such as emergency load shedding. 

Safety Concern 
Role of the FAA Aircraft Evaluation Group

TC agrees with the intent of this recommendation. TC is confident that it has a sound Supplementary Type Certificate (STC) approval process. TC has always been involved in all STC approvals for Canadian design changes. 

TC is involved at the beginning of the project by requiring that the applicant submit a plan. This enables TC to determine that all appropriate analyses will be conducted. TC also conducts detailed technical follow-up audits on selected projects to confirm the adequacy of the analyses and take appropriate corrective action, if required. 

In 2002, TC issued formal guidance material to enhance the consistent use of a certification plan as an important tool early in the certification process prior to any aircraft modifications.


New Recommendation 
Regulatory authorities establish the requirements and industry standard for circuit breaker resetting.

TC agrees with the intent of this recommendation. Although guidance material on the resetting of tripped circuit breakers has been published, TC recognizes a need for further discussions at the international level to ensure the consistent application of these safety measures. TC has proposed that the FAA and the JAA include international discussions on developing a standardized approach through the Transport Aircraft and Engines Issues Group (TAEIG). TAEIG is the appropriate forum to consider this issue on an international level. 

TC has reiterated the best practices regarding the resetting of tripped circuit breakers in a recent article published in TC’s Aviation Safety Letter.


Safety Concerns:
  • Material Flammability Test Requirements for Aircraft Wiring 
  • Limitations of FAR 25.1353 Electrical Equipment and Installation 
  • Potential Limitations of MIL-W-2275/16 Wire 

Interim Recommendation 
A certification test regime be mandated that evaluates aircraft electrical wire failure characteristics and against specified performance criteria, with the goal of mitigating the risk of ignition.




TC recognizes that the Wiring Systems Harmonization Working Group has not been tasked to address this recommendation. However, progress has been made in mitigating the risk of ignition. 

Zonal analysis, an assessment of how the various aircraft systems in a particular area interact, is a well-established part of the certification process.

TC, as part of its involvement in Aging Transport Systems Rulemaking Advisory Committee Working Group 9, has participated in the development of the Enhanced Zonal Analysis Program (EZAP), which adds inspection and maintenance actions for aircraft wiring and the wiring’s immediate environment. EZAP has been implemented for new aircraft and an implementation plan is being developed for in-service aircraft. Implementation will mitigate risk of exposure to ignition sources. 

In addition, TC recognizes that the creation of standards for separation for wiring is beyond the scope of ATSRAC’s tasking. However, the FAA is addressing this concern through a research contract and TC is confident that the results will form the basis for international harmonized standards. 

TC is monitoring ongoing FAA research associated with aircraft electrical wire failure characteristics including the effects of wire and insulation degradation and wiring separation and segregation standards. TC will participate in any harmonization activity related to the outcome of this research program.

Safety Concerns: 
  • Arc Fault Circuit Breaker



  • Certification Flight Crew Reading Light 




  • Standby Instrumentation


  • Advisory A010042-1 (Standby Instrumentation)


  • TC acknowledges that the arc fault circuit breaker may not be suitable to address all ignition scenarios. However, this new device does represent a significant contribution to improving safety especially when considered in combination with other improvements already made or under development. The development of this technology is well advanced and arc fault circuit breakers are now being tested under operational conditions. The Canadian industry is participating in these trials. 
  • TC has evaluated electrically powered fixtures on domestic aircraft certification programs to determine that this condition does not exist. TC continues to perform this evaluation on new domestic programs. Aviation regulatory authorities have been unable to validate that this condition exists on any aircraft type other than the MD-11. 
  • TC recognizes that adequate redundancy in the power supply is an important requirement for standby instruments. Current Canadian standards require three independent electrical power sources, which sustain essential flight instrumentation for flight crews operating transport category aircraft. 
  • TC has reviewed its pilot training standards for transport category aircraft. Current TC training standards stress training in the operation (normal, abnormal and emergency) of aircraft systems and equipment. This includes a requirement for pilot training with failures related to navigation and communication equipment. This does include standby instrument proficiency.

Safety Concerns: 

  • Flight Recorder Duration & Power Supply
  • Underwater Locator Beacon 
  • Non-Volatile Memory 

New Recommendations 
Regulatory authorities, in concert with the Civil Aviation industry, take measures to enhance the quality and intelligibility of CVR recordings. 

Regulatory authorities require for all aircraft manufactured after January 1, 2007, which require a flight data recorder, that in addition to the existing minimum mandatory parameter lists for FDRs, all optional flight data collected for non-mandatory programs such as FOQA/FDM, be recorded in the FDR.

Regulatory authorities develop harmonized requirements to fit aircraft with image recording systems that would include imaging within the cockpit.

TC acknowledges the valuable contributions to improving safety that information collected on cockpit voice and flight data recorders provide to investigative authorities. TC will be examining these new recommendations with a view to enhancing the quality and quantity of information available to investigators. 

However, TC has already taken action to help improve access to valuable information. TC has proposed regulations that were published in Part I of the Canada Gazette on February 15, 2003, requiring a recording capacity of at least two hours for new aircraft. TC expects that the regulation will come into force in the Fall of 2003. Furthermore, an NPA is under development to retrofit existing aircraft with two-hour CVRs. This draft regulatory proposal will follow the normal consultative rule making process.

In addition to improving access, TC is also committed to maintaining the quality of recordings. To accomplish this, TC requires annual intelligibility tests under operational conditions to maintain the quality of CVR recordings. 

TC already requires the use of separate power supplies for aircraft required to have two flight recorders. TC is developing an NPA to strengthen the electrical power requirements. However, TC continues to work with foreign authorities and participate with international committees involved in the development of new standards for independent power supply. 

In relation to the underwater locator beacon, the international European Organization for Civil Aviation Equipment (EUROCAE) working group 50, a body of internationally recognized experts in the field including TC officials, has defined an international standard and recently confirmed that it is adequate.


Interim Recommendations 
As of January 1, 2003, any CVR installed on an aircraft as a condition of that aircraft receiving an original certificate of airworthiness be required to have a recording capacity of at least two hours

As of January 1, 2005, all aircraft that require both an FDR and a CVR be required to be fitted with a CVR having a recording capacity of at least two hours.

A99-03 As of January 1, 2005, for all aircraft equipped with CVRs having a recording capacity of at least two hours, a dedicated independent power supply be required to be installed adjacent or integral to the CVR, to power the CVR and the cockpit area microphone for a period of 10 minutes whenever normal aircraft power sources to the CVR are interrupted. 

Aircraft required to have two flight recorders be required to have those recorders powered from separate generator buses.

See above
















New Recommendation 
Regulatory authorities harmonize international rules and procedures for the protection of cockpit voice and image recordings used for safety investigations.

As noted in the TSB’s report, FDR and CVR recordings are already protected under Canadian law.

Safety Concern 
In-flight firefighting measures

Interim Recommendations 
Appropriate regulatory authorities, in conjunction with the aviation community, review the adequacy of in-flight firefighting as a whole, to ensure that aircraft crews are provided with a system whose elements are complementary and optimized to provide the maximum probability of detecting and suppressing any in-flight fire. 

Appropriate regulatory authorities, together with the aviation community, review the methodology for establishing designated fire zones within the pressurized portion of the aircraft, with a view to providing improved detection and suppression capability. 

Appropriate regulatory authorities, review current in-flight firefighting standards including procedures, training, equipment, and accessibility to spaces such as attic areas to ensure that aircraft crews are prepared to respond immediately, effectively and in a coordinated manner to any in-flight fire.

As a result of SR111, there is a heightened sensitivity within TC and the aviation community regarding the need to immediately begin to prepare to land at the nearest suitable airport in the event of smoke or fire. 

TC agrees that it is a reasonable objective that all crewmembers be capable of coordinating emergency response. TC already has in place comprehensive training standards for flight crews and flight attendants, which meet and, in some cases, exceed international norms. 

The Flight Attendant Training Standard requires that cabin crew conduct firefighting drills every year. The firefighting drills must include simulated fires in the following locations: cabin (e.g. under seat, overhead bin, closet); galley (e.g. garbage bin, upper electrical panel, oven); confined (e.g. waste bin, lavatory); and hidden areas (e.g. behind panels). In addition, Canadian standards require that cabin crew demonstrate, once every three years, proficiency with required onboard firefighting equipment by extinguishing an actual fire. 

The Flight Crew Training Standard requires emergency procedures training for pilots and includes training on fire in the air and on the ground as well as practical training on the use of fire extinguishers. The standard also calls for annual crew resource management training so that crew understand their responsibilities to minimize the time required to assess and gain control of emergency situations. Canadian standards require that pilot and flight attendants participate in joint training exercises to allow for a coordinated response to any possible in-flight emergency. 

To further minimize the risk of fires in inaccessible locations, TC has drafted NPAs, which are scheduled to proceed through the formal Canadian regulatory process in the Fall of 2003, for the new standard for enhanced flammability criteria for thermal acoustic insulation materials. TC will continue to work with the international community on aircraft design related initiatives, such as the improved electrical system protection.

In addition, TC is working with the FAA’s International Aircraft Systems Fire Protection Working Group (IASFPWG), to investigate the issues associated with fires in various hidden areas as well as the technical feasibility of fire detection and suppression systems for those areas.


Safety Concern 
Checklist Modifications 

Interim Recommendations 
Appropriate regulatory authorities take action to ensure that industry standards reflect a philosophy that when odour/smoke from an unknown source appears in an aircraft, the most appropriate course of action is to prepare to land the aircraft expeditiously. 

Appropriate regulatory authorities ensure that emergency checklist procedures for the condition of odour/smoke of unknown origin be designed so as to be completed in a timeframe that will minimize the possibility of an in-flight fire being ignited or sustained.

TC recognizes that international regulations or standards have not been developed for checklist design. 

Since 1987, TC has required that aircraft flight manuals for all transport category aircraft include an additional instruction that calls for an immediate landing at a suitable airport in the event of an in-flight fire, if there is any uncertainty of it being extinguished. Other authorities and foreign manufacturers have recognized the soundness of TC’s approach and are now adopting a similar approach. 

TC is also participating in international fora to develop a standardized philosophy for checklist design. 

In the short-term, TC is reviewing the relevant aircraft flight manual procedures for Canadian-designed aircraft with a view to reducing the time required to complete critical checklists. TC will be requesting the FAA and JAA to undertake the same review. TC will also propose to regulatory authorities that a joint working group be formed to develop guidance material for checklist development. 

TC incident statistical analysis indicates a heightened sensitivity to smoke in the cockpit and the increased frequency with which flight crews are landing immediately at the closest airport.


Interim Recommendation 
As a prerequisite to certification, all aircraft systems in the pressurized portion of an aircraft, including their sub-systems, components and connections be evaluated to ensure that those systems whose failure could exacerbate a fire in progress are designed to mitigate the risk of fire-induced fires.

This is an extremely complex issue that requires international coordination. TC has proposed to the FAA that the TAEIG generate a harmonized working group tasking to establish methods for the assessment of the consequences of fire-induced progressive systems failures. 

Progress made in the area of material flammability is a key element in addressing this recommendation. This includes the significant progress made with the Radiant Panel Test (RPT) and the review of other materials by the IAMFTWG such as end caps, hook and loop, tapes, adhesives, etc.


Advisory A010020-1 
TSB suggested TC review controller training requirements. Consideration should be given to the need for additional training regarding aircraft emergency scenarios prior to the initial issuance of a licence to air traffic controllers under the Canadian Aviation Regulations (CARs). Specifically, further training may be warranted that provides the requisite knowledge and skills so that controllers are better able to provide safe and expeditious air traffic control (ATC) services to aircraft experiencing emergency or distress conditions. The need for regular continuation training and refresher exercises regarding emergency scenarios should also be considered.

TC worked with NAV CANADA to verify that the basic ATC training syllabus was modified to include a dedicated module dealing with the handling of aircraft experiencing in flight emergencies. Simulator scenarios have been enhanced. The annual refresher module given to each ATC now incorporates review of emergency procedures. 

TC will continue to audit training through its regulatory audit program.







MD-11 Specific 


  • A980031-1 MD-11 Wiring Issues 
  • A000008-1 Flight Crew Reading Light
  • A000042-2 MD-11 Standby (Secondary) Instruments 

Info Letters 

  • A000061-1 Flight Crew Reading Light
  • A000062-1 & A000062-2 MD-11 Overheating Conditions in Overhead Aisle and Emergency Light Fixtures 


  • TSB Alert to Stakeholders on the In-Flight Entertainment Network/STC
The MD-11 is not type certified in Canada and no Canadian air carriers are operating the MD-11 aircraft. For details on the safety record of the MD-11 or responses to these issues identified by the TSB, contact the FAA or the NTSB, as the aircraft is manufactured in the United States. The FAA is the authority responsible for type design and all matters of continuing airworthiness.











Last updated: 2003-03-27 Top of Page Important Notices



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