Anon_Insider
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Member # 43

posted March 06, 2003 12:31 AM                     The technical ability and integrity of the crash investigators has never been in question. It's whether the Swissair 111 crash investigation has been politicized at higher levels.

Although the Transportation Safety Board of Canada (TSB) has, on several occasions, recommended safety initiatives as they uncovered deficiencies during the investigation, they have so far chosen to remain completely silent on the FAA's role in the certification and installation mess of the in-flight entertainment system. Not once did they call for an investigation into the matter.

Following the stunning February 17, 2003 article in USA Today citing non-existent Federal Aviation Administration (FAA) oversight of the Swissair project, and potential corruption, eyes now turn towards the Transportation Safety Board in Canada to see how all of that will figure into the final report, to be released in a few weeks.

Will the Transportation Safety Board of Canada come down hard on the FAA, and the system's certification, or will they merely clip a few paragraphs of findings from the FAA's own internal post-crash audit? Will they also address Hollingsead's poor installation?

Many people might be surprised to know that the mandate of the Transportation Safety Board of Canada is not to find the cause of a crash, but more generally, to 'advance aviation safety'.

This mandate could prove to be a disappointment to those that are expecting the Swissair 111 final report to identify the exact ignition source of the electrical fire. To understand why, one needs to examine some history of the Transportation Safety Board of Canada, as well as some more recent events and comments leading up to the conclusion of the Swissair 111 investigation:

· On Dec 12, 1985, an 'Arrow Air' plane crashed near Gander Newfoundland, killing 248 US soldiers, and 8 crewmembers. The Canadian Air Safety Board (CASB) investigated, which was the predecessor agency to what is now known as the Transportation Safety Board of Canada. The Board was split 5 to 4 over the cause of the crash. The 5 majority members felt that the most probable cause of the crash was ice contamination on the leading edge and upper surface of the wings. The 4 minority members believed that it was due to an in-flight fire, resulting from detonations of undetermined origin brought about catastrophic system failures. Their report stated that "the aircraft's trajectory and performance differed markedly from that which could plausibly result from ice contamination. The aircraft did not stall. Accordingly, we cannot agree - indeed, we categorically disagree - with the majority findings." The public cried cover-up, and the split virtually destroyed the credibility of the CASB.

Many years later, Benoit Bouchard (The TSB Chairman) described his solution:
"As a former Minister of Transport, I have a unique perspective on Safety Boards because it was during my tenure that I inherited the responsibility for what was, at the time, a very fractious Board, and had to come up with a way to solve the problem. I introduced new legislation to deal with the problems of that Board... by eliminating it...and creating a new one."

His comments suggest that today's Transportation Safety Board of Canada is structured in such a way that dissenting views cannot occur in the same manner, or simply won't be tolerated.

· On July 11 1991 a Canadian 'Nationair' DC-8 crashed in Jidda, Saudi Arabia, killing 263 people. About 11 minutes after takeoff, the pilots reported that a tire had burst, and that the aircraft was losing hydraulics. They declared an emergency. On its final approach, the pilots said that they were having difficulty controlling the aircraft during turns, and they reported a fire onboard the aircraft in the cabin area. Moments later, the airplane crashed and exploded in flames. Nationair immediately denied any responsibility, and its president blamed "debris on the runway" as the cause. The team investigating the crash included representatives of the Transportation Safety Board of Canada, the NTSB, Federal Aviation Administration, and Nationair. Ultimately, Nationair was found to be responsible for the crash, having falsified records, and flying an unairworthy aircraft. However, in August 1991, Transport Canada conducted a post-crash 'safety review', but for many years, they blocked the release of the report through the Access to Information Act, arguing that the effectiveness of the investigation depended on the candid cooperation of airlines and their employees. By exposing the report to public view, it would have a 'chilling effect' on their willingness to participate in future safety reviews. The report was finally released in February 1998 under a Federal Court of Appeal ruling, only through the exhaustive efforts of a Canadian named Ken Rubin, a private consultant and 'freedom of information' expert. In the 1991 Post-Crash Safety Report, it was reported that Transport Canada had found that its maintenance audits of Nationair had been done without corrective or follow-up action to modify or improve program quality. Ken Rubin found the report showed evidence of a problem that plagued the airline, and inept inspection, which Transport Canada attempted to cover up. The Federal Court acknowledged that this case forcefully reminded government not to be so quick to applying Access to Information exemptions, as is common in Ottawa, but to look first and foremost to releasing records for the public's benefit and safety. However, the court also said that if a 'chilling effect' were substantiated, other means were available to Parliament to make future reports confidential.

· On September 2, 1998, Swissair Flight 111 crashed, and investigators almost immediately focussed on the in-flight entertainment system.

· On Oct 26, 1998, the Transportation Safety Board of Canada reported on their website that "investigators are checking the maintenance records on the IFE system."

· On Oct 27, 1998, the Transportation Safety Board of Canada said: "more work is being done on examining the IFE system."

· On Oct 28, 1998, a two-day meeting was held in Zurich where officials involved in the investigation were concerned about the possible implications of the IFEN system in the crash. The meeting included officials of Boeing, the TSB, NTSB, Swiss Federal Office for Civil Aviation (FOCA), IFT, Hollingsead, Swissair, and SRTechnics. The IFEN design, installation, and certification issues were discussed. At the end of the meeting, Swissair decided to deactivate all IFEN systems installed on Swissair aircraft. The next day, Swissair announced that it was voluntarily disconnecting the IFENs in fifteen MD-11's and three 747's as a 'precautionary measure'.

· Two months after the crash of SR111, Benoit Bouchard was quoted in the Halifax Herald that he would consider holding a public inquiry into the crash. It's believed that its never been mentioned again since.

· On Nov 9, 1998, the FAA commenced its own internal review into the certification of the in-flight entertainment system, called the Special Certification Review (SCR) report.

· On Nov 11, 1998, TSB investigators were in Zurich examining other MD-11 aircraft with the in-flight entertainment system installed.

· By December 1998, TSB investigators stated that they had recovered "a number of power-supply wires from the entertainment system" that exhibited arcing damage.

· On May 5, 1999, speaking at an International Symposium on Transportation Recorders in Arlington Virginia, Benoit Bouchard stated: "It is not the purpose of this activity (investigation of accidents) to apportion blame or liability." "In the Swissair 111 accident near Peggy's Cove there has been, in Switzerland, an allegation of "manslaughter through negligence". An investigating judge has been assigned in Switzerland and the Canadian Department of Justice has been asked to obtain our files. While we like to cooperate, we will resist the use of our information for the purposes of prosecutions with extreme vigor. For the crews and the companies involved, this interest in criminal charges must be alarming. From the perspective of the accident investigation agency it is very worrisome. The effect of bringing criminal charges against crews and companies can be very detrimental to the investigation and to safety. If crews and companies are fearful about speaking freely to investigators, the investigators must necessarily take longer and may not even succeed in identifying safety problems."

· On June 14, 1999, the FAA quietly completed its review of the in-flight entertainment system certification. The SCR report was then held back for an additional year to include some follow-up recommendations.

· Shortly after the FAA's SCR report was released, Santa Barbara Aerospace 'voluntarily surrendered' their Designated Alteration Station authority.

· On August 5, 1999, Swissair and Boeing, in what some call an unusual move, agreed to assume joint financial responsibility for any monetary damages that might result from the crash of Swissair Flight 111. Swissair offered $300M to compensate the relatives of the 229 people killed in a 1998 crash off the coast of Nova Scotia, provided that the victims' families agree not to pursue 'punitive' damages. Families turned down the deal.

· In November 1999, Swissair technicians pointed investigator's attention to potential overheating problems with a pilot's map light in the cockpit. This led to the TSB issuing a Safety Advisory ordering inspection of map lights on other aircraft. Was this an attempt to draw attention away from the in-flight entertainment system? As far as punitive damages are concerned, a faulty map light isn't anywhere near the same league as an improperly certified and installed entertainment system.

· On May 9, 2000, at a Canadian Aviation Safety Seminar held in St. John's Newfoundland, Benoit Bouchard said: "In Canada, our law does not ask us to find either cause or probable cause. We are instructed to make findings 'as to', or about, the causes and contributing factors and to identify safety deficiencies. Safety deficiencies can be thought of as risks within the system for which there are not adequate defenses. Attempts to determine the cause are almost inseparable from the assignment of blame - and this is something for us to avoid. It takes away from our mandate. When we get close to assigning blame, we tend to get our work drawn into the courts. Court processes are effective for determining who is at fault or who broke the law. Usually time is not a major issue in resolving court cases. In accident investigation, time is of the essence in identifying safety problems and making them known. We must have a system where people will come forward quickly with safety-related information. This will happen only if they do not have to worry about the consequences of having provided it. When we focus on cause we may end up keeping our investigations so narrow that we might miss those safety deficiencies unrelated to cause."

· On December 4, 2000, at a TSB press conference held in Shearwater Nova Scotia, and only half-way into the investigation, Benoit Bouchard declared: "I cannot guarantee that we will ever have a definitive answer as to the cause of the accident."

· On Aug 28, 2001, during a news conference on the third anniversary of the crash, Benoit Bouchard stated: "We're not just looking for a single cause, because there is seldom just one. Accidents, especially catastrophic ones, are always intricate webs of circumstances-a giant puzzle of things that can and do go wrong. In the case of Flight 111, we faced a puzzle of astounding magnitude."

· In 2001, lead investigator Vic Gerden said the best investigators may be able to do is pinpoint a 'chain of events' that contributed to the disaster.

The in-flight entertainment system was quickly fading into obscurity.

Once a leading item of focus in the investigation, the Transportation Safety Board of Canada suddenly seemed hard pressed to acknowledge that the in-flight entertainment system even existed. References to it posted on their website during their periodic 'investigation updates' seemed to drop off at about the same time that the FAA commenced its internal review into the entertainment system certification. In fact, during their August 28, 2001 press conference, the Transportation Safety Board of Canada made no mention of the entertainment system whatsoever. However, the 'map lights' got mentioned. The Transportation Safety Board of Canada has now removed all of the early 'investigation updates' from their website.

· On Feb 27, 2002, Chief Judge James T. Giles of the United States District Court in Pennsylvania handed down a decision dismissing all punitive damage claims arising out of the crash of Swissair Flight 111. The decision also found that while dismissing all punitive damage claims in the SR111 litigation are significant from the point of view of future precedent, "they have limited application to the claims arising from the crash of SR111 because the majority of those passenger cases have now been resolved." Under the Death on the High Seas Act (DOHSA) invoked in this case, compensation is based on the income lost by the victim as a wage earner, not the emotional losses suffered by surviving family members.

· On September 2, 2002, someone identifying himself as 'beanspiller', claimed on this Swissair111.Org message board that he had received information from a source close to the investigation that told him that the entertainment system had caused the crash. He also said that early in the investigation, authorities had suspicions that the entertainment system was involved in the crash. They did some preliminary work in that area, and just when they were getting somewhere with their work, they were "directed" to look for other "probable" causes for a crash. After looking at all other probable causes, they kept coming back to the entertainment system. Beanspiller was summarily investigated by the RCMP. What does that tell you?

So why has this investigation taken 4 1/2 years?

Besides passing the front end of the airplane under a microscope, were there higher level objectives at play here, such as:
1) Mitigating liability to Boeing, Swissair, Hollingsead, and the other companies involved?
2) Allowing the FAA time to 'get its house in order' following their embarrassing lack of project oversight?

With respect to the first objective, the Transportation Safety Board of Canada has clearly shown that they will "resist the use of our information for the purposes of prosecutions with extreme vigor." To that end, the TSB has carefully controlled all outbound information. I presume that the Canadian 'Access To Information' process hasn't been too accommodating either. Just try obtaining information from the Canadian Access To Information or U.S. Freedom Of Information Acts, after an aircrash. Suddenly, they're not as accessible as you think. You will get every excuse under the sun, most commonly that they are 'short staffed', and various other delay tactics. Although these agencies have strict requirements for initial response times (i.e. 10 days), once they've acknowledged your application, there's no time limit on completing requests for information. They are able to gauge the sensitivity (or potential embarrassment) of each request, and adjust the waiting time accordingly. Get used to waits in the order of years, not weeks. I hope to see the day where these agencies are obligated to complete all requests within 60 days.

To be sure, the investigation has lasted long enough to ensure that all of the claims have been settled in advance of the final report.

With respect to assisting the FAA, I can only speculate that someone from the FAA called up the TSB and said, hey, we've got a real mess here. Do you mind helping us to contain it, so long as we make sure to fix the problem so that it doesn't happen again? The USA Today newspaper article shows just how busy the FAA has been in this area since the crash.

One of the things that I have difficulty accepting is the comfortable relationship between the investigators and the manufacturers & companies. They are invited to participate in the investigation process on the reasoning that they will share information much more freely, without the threat of prosecution. But along with their participation come the powerful legal teams that represent them, which I believe, have the ability to influence the direction of the investigation(s), and have probably helped to shape the NTSB and TSB into what they are today. It may go a long way to explain why investigations avoid zeroing in on specific causes, and instead try to identify a number of 'safety deficiencies', and 'contributing causes'.
(The exception to the rule always seems to be 'pilot error'). Stemming from these findings are then lists of 'safety recommendations'. It's all rather watered down.

Furthermore, last August, the Transportation Safety Board of Canada released a confidential draft report to what they initially termed, "parties of interest". Again, it was the very manufacturers and companies that were either involved, or indirectly involved, in the Swissair project. The families were not allowed to see the report.

Face it, the system is skewed to favor big business.

So what will this $50M investigation actually buy?

· The recommendation to replace Insulation Blankets?
Think again. In September 1996, Boeing started advising operators of MD-80 and MD-11 aircraft to discontinue using insulating material that was covered with Metallized Pet (MPET). Tragically, Swissair 111 had completed its Heavy Maintenance Visit, and had its entertainment system installed just one month prior to the issuance of a Boeing Service Bulletin advising operators to remove it. Besides, what are combustible insulating blankets doing in airplanes in the first place?

· The recommendation for improved Fire detection and suppression systems?
That's not new. In 1996, U.S. Airlines announced at a meeting with President Clinton and Vice President Gore, that they would voluntarily install fire detection systems in all airliner cargo holds. That decision grew from an American Airlines DC-9 crash in 1988 in which the NTSB recommended to the FAA that fire detection and suppression systems should be required. Despite that, the FAA didn't mandate it at the time because of cost. But the crash of ValuJet in May 1996 caused the FAA to announce that a 'newly-concluded analysis' has determined that such systems could be extended to all passenger aircraft cargo compartments.

· The recommendation that the FDR / CVR have separate power sources?
You mean they never did?

· The recommendation that the emergency checklist should include provisions for landing immediately when there's smoke or fire?
Seems somewhat academic.

The sad reality is that the $50M may well go more into protecting the FAA's behind, than providing real answers to the victim's families.

The USA Today article shows that there's a need for a thorough investigation -- maybe even a criminal investigation -- into how those systems were certified and then installed so quickly on Swissair airplanes. But I guess the authorities are too busy investigating beanspiller instead.

Anon_Insider