Member # 43
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
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
"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
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
· 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
· 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
· 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
· 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
· 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
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,
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
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
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
You mean they never did?
· The recommendation that the emergency checklist should
include provisions for landing immediately when there's smoke
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.