UNCLAS HALIFAX 0093

SIPDIS

DEPT FOR CA/OCS, WHA/CAN, AND EB/TRAN
USDOT PLEASE PASS NTSB

E.O. 12958: N/A
TAGS: CASC EAIR CA US
SUBJECT: CANADIAN TRANSPORTATION SAFETY BOARD
RELEASES FINAL REPORT ON CRASH OF SWISSAIR FLIGHT 111



1. THE TRANSPORTATION SAFETY BOARD OF CANADA (TSB) TODAY RELEASED
ITS FINAL REPORT ON SWISSAIR FLIGHT 111, WHICH CRASHED OFF THE
COAST OF NOVA SCOTIA ON SEPTEMBER 2, 1998, KILLING ALL ABOARD,
INCLUDING 103 AMERICAN CITIZENS. THIS REPORT MARKS THE
CONCLUSION OF THE TSB'S LONGEST AND MOST EXTENSIVE CRASH
INVESTIGATION EVER, CONDUCTED AT A TOTAL COST OF C$ 57 MILLION.


2. THE TSB CONCLUDED THAT THE ONBOARD FIRE WHICH LED TO THE CRASH
OF SWISSAIR 111 STARTED IN A HIDDEN OVERHEAD AREA ON THE
STARBOARD SIDE OF THE PLANE JUST ABOVE AND AT THE REAR OF THE
COCKPIT AREA. THE SOURCE OF IGNITION WAS AN ARCING EVENT IN THE
AIRCRAFT'S ELECTRICAL WIRING. THE TSB PINPOINTED ONE PARTICULAR
SECTION OF WIRING FROM THE AIRCRAFT'S IN-FLIGHT ENTERTAINMENT
SYSTEM FOR BUSINESS CLASS PASSENGERS AS BEING ASSOCIATED WITH THE
INITIAL ARCING EVENT, THOUGH THEY COULD NOT SAY WITH CERTAINTY
THAT THE ARCING THAT OCCURRED THERE WAS IN FACT THE LEAD EVENT.
THE TSB CONCLUDED THAT ARCING ALSO OCCURRED AT OTHER POINTS IN
THE WIRING FOR THE IN FLIGHT ENTERTAINMENT SYSTEM WHICH WERE NOT
RECOVERED, MAKING IT IMPOSSIBLE TO ISOLATE THE LEAD ARCING EVENT.
THIS ARCING IGNITED THE METALLIZED POLYETHELENE TEREPHTHALATE
(MPET) MATERIAL ON THE INSULATION BLANKETS ABOVE THE CEILING OF
THE RIGHT REAR COCKPIT AREA. THE TSB CONCLUDED THAT THE MPET
BLANKETS WERE EXCESSIVELY FLAMMABLE AND THAT ABSENT THE PRESENCE
OF FLAMMABLE MATERIAL IN THE VICINITY OF THE INITIAL ARCING
EVENT, THE DISASTER WOULD NOT HAVE OCCURRED.


3. THE TSB NOTED THAT FIRE/SMOKE DETECTION AND SUPPRESSION
DEVISES WERE NOT PRESENT IN THE AREA WHERE THE FIRE STARTED, AND
WERE NOT REQUIRED AT THAT TIME. THE TSB CONCLUDED THAT THE
FLIGHT CREW DID NOT HAVE THE NECESSARY TOOLS, PROCEDURES, OR
TRAINING TO LOCATE AND ELIMINATE THE FIRE BEFORE IT BECAME
UNCONTROLLABLE. THE TSB ALSO CONCLUDED THAT AIR CIRCULATION
CHARACTERISTICS ABOARD THE AIRCRAFT VENTED SMOKE AWAY FROM THE
CREW INITIALLY. THIS CONTRIBUTED TO A DELAY IN RECOGNIZING THE
EXTREMELY SERIOUS NATURE OF THE SITUATION, AND LED THEM INITIALLY
TO ERRONEOUSLY BELIEVE THAT THE SMELL THEY DETECTED WAS THE
RESULT OF AN ANOMALY IN THE AIR CONDITIONING SYSTEM INSTEAD OF AN
ONBOARD FIRE.


4. HOWEVER, THE TSB ALSO CONCLUDED THAT AN ACCURATE EARLY
ASSESSMENT OF THE SITUATION WOULD STILL NOT HAVE GIVEN THE CREW
OF SWISSAIR 111 SUFFICIENT TIME TO EXECUTE A SAFE EMERGENCY
LANDING IN HALIFAX. THE TSB CONCLUDED THAT, GIVEN IDEAL
CONDITIONS, THE EARLIEST MOMENT THAT SWISSAIR 111 COULD HAVE
LANDED WAS 22:27 LOCAL TIME. HOWEVER, THE ONBOARD FIRE RESULTED
IN A RAPID DETERIORATION OF FLIGHT CONTROL SYSTEMS IN THE COCKPIT
AT 22:25. THE TSB THEREFORE CONCLUDED THAT THE CREW WOULD HAVE
LOST CONTROL OF THE AIRCRAFT SHORT OF THE RUNWAY EVEN IF THEY HAD
ACTED IMMEDIATELY TO EXECUTE AN EMERGENCY LANDING AT THE MOMENT
THEY FIRST SMELLED SMOKE.


5. IN ADDITION TO THE 14 AVIATION SAFETY RECOMMENDATIONS ALREADY
MADE IN THE COURSE OF THIS INVESTIGATION, THE TSB RELEASED AN
ADDITIONAL NINE RECOMMENDATIONS IN CONJUNCTION WITH THEIR FINAL
REPORT. THESE RECOMMENDATIONS DEAL WITH TESTING AND FLAMMABILITY
STANDARDS FOR INSULATION MATERIALS, WITH AIRCRAFT ELECTRICAL
SYSTEMS INCLUDING CERTIFICATION OF ADD-ON ELECTRICAL SYSTEMS FOR
COMMERCIAL AIRCRAFT, AND IMPROVEMENTS TO THE CAPTURE AND STORAGE
OF IN FLIGHT DATA.


6. THE TSB OFFICIALS PRESENT EMPHASIZED THAT THE PURPOSE OF THEIR
INVESTIGATION IS TO IMPROVE AVIATION SAFETY AND TO PREVENT FUTURE
TRAGEDIES, NOT TO ASSIGN BLAME OR LIABILITY FOR THE CRASH OF
SWISSAIR 111. THEY EXPRESSED CONFIDENCE THAT THE RECOMMENDATIONS
PRODUCED AS A RESULT OF THEIR INVESTIGATION HAVE AND WILL
CONTINUE TO IMPROVE AVIATION SAFETY. WHETHER THE INFORMATION IN
THEIR FINAL REPORT WILL PROVIDE ANY MEASURE OF CLOSURE OR
SATISFACTION FOR THE FAMILIES OF THE VICTIMS OF SWISSAIR REMAINS
TO BE SEEN. THE TSB REPORT IS AVAILABLE IN FULL AT:
HTTP//WWW.TSB.GC.CA.

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