Subject: The KATZ Letter & the sr111 Update
Date: Mon, 28 Jun 1999 22:17:54 +0800
The first impression I get is that their PR Team has given the Board
a "heads up" on the fact that the anniversary will be both
a time of great emotion (and perhaps criticism) over the slow unraveling
of the root causes of the disaster. Obviously this initiative is meant
to both stave off criticism of Swissair and to reorient the emotions
towards the memorial as a commemorative event. The more sombre, ceremonial
and sanctimonious they are about the memorial events, the more that
criticism will be deflected from the airline (in their view). It's
one of those "we're all in this together" style of approaches
(e.g. "we remain true to....").
I think that they are probably right. It will be a media feast and
probably more than one book will hit the news-stands. However Swissair
will "never enter into speculation of any kind".
But they will be sending you "The Update" every few weeks.
It's a move designed to convey a sense of ongoing commitment and I suppose you'd have to
say that it's a rational move on their part.
The Update
"......and Swissair has no free access to the information
involved." The fact that they have their own specialists on the ground in
Shearwater would indicate to me that they are as close to the investigation as anyone
could be.
"internal investigations are being conducted at Swissair and
Boeing" This could be anything from component teardown to an examination of
CRM training techniques.
Examination of the Wiring
"Strong indications....." This paragraph reveals
very little beyond the fact that, as everyone knows, electrical glitches that progress
beyond simple component or system failure are very difficult, if not impossible, to
analyse - either at the time or later.
"This means that the number of possible
sources of any electrical malfunction is correspondingly large".
I cannot resist saying here that while everyone concedes that an electrical
short, fire, smoke, arc, flashover (let's call it an event) can happen
anywhere in a system, no one is taking it that logical step further
and saying: "That indicates to me that we're going to have to
look at the whole question of wiring in aircraft. Beyond the question
of the vulnerability of certain types of wiring insulation, there's
the question of routing of system wiring and the loss of redundancy
caused by bundling wires together" The latest FACT that has been
uncovered is that there is one focal duct in the cabin/cockpit bulkhead
through which all wiring must pass. Obviously any fire there (as in
sr111) would have to have a catastrophic effect on aircraft systems.
I think that Swissair is preparing itself publicly for these sorts
of revelations, ones that bring into question the fundamental airworthiness
of the MD-11
The Insulating Thermal/Acoustic Blankets
The Swissair exculpation has always been that HB-IWF had its heavy
maintenance about two months before the McDonnell Douglas SB came out advocating that the
blankets be replaced. However I believe that two types were found in the sr111 debris so
perhaps this was partly underway. The catharsis for this as an issue was the FAA mandating
their replacement, but I don't think that an absolute time-limit was specified. It has
been conceded that the blankets are flammable but not that they caused/were involved in
the sr111 fire. More significant is the fact that the FAA was forced eventually to accept
that the flammability test itself was flawed. If they were forced into the same corner on
wiring insulation tests then that would indeed be something.
Power Supplies for the Flight Data Recorder and CVR
In a way this has also become a bit of a red herring (like oxygen generators aboard
VJ592). At the end of the day you have to belabour the odd point in an accident
investigation report. You want to be able to do that:
a. Because you can't not say anything about a whole range of things you'd rather
not alarm the public about and
b. Having a few fairly innocuous and believable focal points tends to concentrate the
public's mind more.
c. If those focal points are (let's say) chafed wiring from R1 & L1 doors, a
faultily-wired IFEN system and a poorly configured elec supply for the black boxes, well
that's enough but they could throw in also that the blankets had to be changed because
they fail the "more stringent" new series of tests.
Now this would be easily handled by both the NTSB and FAA because there's no focus on
wiring insulation or any other potentially disruptive issues. They simply fine the IFEN
installers, put it down to faulty wiring installation practices and everyone gets on with
their lives. It becomes a historical "once off".
Examination Of Cockpit Procedures
"Checklists tell pilots exactly what to do in various inflight
situations. Emergencies are dealt with using a series of special emergency checklists
which are designed to ensure that the crew continues to work as effectively as possible,
even in situations of extreme stress and pressure of time". Well, three
observations here:
a. I guess Mr Katz's view is typical of a perception that most airline executives have of
their crews - automatons marching to the beat of a checklist. Most airline execs don't
really want to become involved in the nitty-gritty of operations. They have Ops, Training,
Simulator and Standards Staff who can do that.
b. He concedes that pressure of time, extreme stress and working effectively are all
considerations in possible outcomes. So too is cost-cutting, design deficiencies and
poorly designed checklists.
c. When you design an operating system you should examine it closely for weak points and
then redesign to eliminate those. The MD-11 never incorporated any re-design following on
from a human factors evaluation. Once the pilots were committed to their course of action
by the aircraft design (the checklist, the SEAsw and lack of a third man) they were also
destined to die in their seats. Each confounding but inexorable development in the sr111
emergency was followed by another, even more perplexing and insoluble. It was quite
apparently an escalating scenario that could only have been resolved by an escape system.
In the military they have ejection seats. In an airliner it's called redundancy. The sr111
crew didn't have that option. There was no redundancy handle for them to pull in order to
short-circuit the culmination of succesive systems failures. Simply
put, the power stayed on the wires and, not surprisingly, the fire worsened.
Outlook
This is quite a bland lapse into officialese that essentially says: "We've told you
all we know and it's really out of our hands".
However unspoken in the statement: "Any technical or other
improvements that emerge from the investigation will be implemented immediately"........is
the obligatory rider "...that the FAA endorses and approves". Obviously
there will be no unilateral Swissair incorporation of modifications or revision of
procedures. And I'm also not sure that, in the absence of any FAA Directive, that they'd
know just how to go about that. In fact they'd probably have to put new internal
procedures in place.
It is a suitably pitched monograph, full of bewilderment and sympathy with a sprinkling of
self-pity. You could almost believe that Swissair doesn't know why it should have happened
to them. I hope that that is not genuinely the case.
regards
IASA Australasia |
