Swissair Flight 111

Path to the Swissair Flight 111 memorial, Whalesback. -8

Swissair Flight 111

2 September 1998 10:31pm ADT

Photographs of Memorial

Whalesback Halifax Regional Municipality Nova Scotia

Located on the west side of Highway 333

GPS location: 44°30’23″N 63°55’59″W

Google map

Also see: Bayswater memorial, Swissair Flight 111

Swissair Flight 111 memorial, Whalesback. Looking southwest toward the crash site.
Swissair Flight 111 memorial, Whalesback.
Looking southwest toward the crash site.

Photographed on 25 August 2003

Swissair Flight 111 memorial, Whalesback, looking southeast.
Swissair Flight 111 memorial, Whalesback,
looking southeast toward Peggy’s Cove lighthouse.

Photographed on 25 August 2003

Swissair Flight 111 memorial, Whalesback.

Photographed on 15 November 2002

Swissair Flight 111 memorial, Whalesback.

Photographed on 10 November 2002

Map showing location of the Swissair Flight 111 memorials
Map showing location of the Swissair Flight 111 memorials
at Whalesback in Halifax Regional Municipality,
and Bayswater in Lunenburg County.

Swissair Flight 111 memorial, Whalesback

Photographed on 15 November 2002

Swissair Flight 111 memorial, Whalesback

Photographed on 15 November 2002

Path to the Swissair Flight 111 memorial, Whalesback.
The path to the memorial.

Photographed on 10 November 2002

Table of Contents

Swissair Flight 111 Archives

# Top Ten

# Air Safety Week


# Lunenburg Progress-Enterprise

# Bridgewater Bulletin

# Halifax Chronicle-Herald

# Halifax Daily News

# Nova Scotia Government press releases

# Swissair press releases

# DND Marlant press releases

# RCMP press release

# Journal of Air Transportation

# Aviation Safety & Security Digest





# IASA: International Aviation Safety Association

# IFALPA: International Federation of Air Line Pilots’ Associations

# IFT: Interactive Flight Technologies Inc.

# SBA: Santa Barbara Aerospace Inc.

# TSB: Transportation Safety Board (Canada)

# NTSB: National Transportation Safety Board (U.S.)

# JAA: Joint Aviation Authorities (Europe)

# EASA: European Aviation Safety Agency

# ALPA: Air Line Pilots Association International

# NADA: National Air Disaster Alliance

# Daily Telegraph

# London Times

# New York Times

# Seattle Post-Intelligencer

# Seattle Times

# USA Today

# Washington Post

# Huffington Post

# Newsweek

# Time

# US News & World Report

# U.S. Dept. of Transportation

# United States Navy press releases

# Aviation Safety Network

# Yahoo News


# Other

# 2008 Sep 2: Tenth Anniversary of the Crash

Transportation Safety Board

TSB Official Report on Swissair Flight 111

Published 27 March 2003

Table of Contents

1.0 Factual Information

1.14 Fire

1.6.10 Electrical System

1.9 Communications

1.11 Flight Recorders

2.0 Analysis

3.0 Conclusions

4.0 Safety Action

4.3.3 Aircraft Wiring Issues

5.0 Appendices

Appendix C Swissair ‘Smoke of Unknown Origin’ Checklist

Swissair 111 Investigation Report: Executive Summary
Transportation Safety Board

Transportation Safety Board of Canada: Official Report on Swiss Air Flight 111

(Copy archived in Canada)

Transportation Safety Board of Canada: Official Report on Swiss Air Flight 111

(Copy archived in Switzerland) PDF: 32 megabytes

Brief history of the disaster
On 2 September 1998 at 2118 ADT Swissair Flight 111, a McDonnell Douglas MD-11 aircraft,
departed John F. Kennedy airport, New York, en route to Geneva…

Information and discussion
of the crash, investigation, victims and
survivors of Swissair 111, what went wrong, why, who was responsible
and how will such tragedies be prevented in the future…

Lost at Sea: The NewsHour with Jim Lehrer Transcript
3 Sep 1998
Last night, Swissair Flight 111 plunged into the ocean off the coast of
Nova Scotia, leaving no survivors. After a background report, a former
Federal Aviation Administration chief discusses the investigation that will
try to determine what went wrong.

PBS NOVA: Crash of Swissair Flight 111

Photograph: Swissair McDonnell Douglas MD-11 HB-IWB
taking off from Geneva on 25 February 1996

Photographed by Stefano Pagiola

Air Traffic Control Preliminary Transcript of Swissair Flight 111
2 Sep 1998

Swissair Flight 111
Nationmaster Encyclopedia
The aircraft, a McDonnell Douglas MD-11, serial number 48448,
was manufactured in 1991… The airframe had a total of 36,041 hours.
The three engines were Pratt & Whitney 4462s. The cabin was configured
with 241 seats (12 first-, 49 business-, and 180 economy-class).
First- and business-class seats were equipped with an in-flight
entertainment system…

Before Swissair Flight 111 crashed, the pilot reported an in-flight fire.
Have such fires happened before? If they have, do all on board usually die?

Swissair flight 111

Fact Sheet: State Department on Swissair/Delta 111 Crash

Bill No. 115: Flight 111 Special Places Memorial Act

Swissair Crash Tests Relations With Insurers
Wall Street Journal

Swissair’s Drama – SR111
Aircraft Crashes Record Office, Geneva

Swissair 111 Reconsidered
by William Henry,

How to crash an in-flight entertainment system
2007 Feb 09

ISASI; International Society of Air Safety Investigators

Swissair Flight 111: The Accident that redefined CRM

Speech by Mr Jeffrey G. Katz President and CEO, Swissair

International Aviation Club, Washington, DC, 16 May 2000

Swissair 111 Memorials To Carry Airline Name And Flight Number

Jack Gallagher, Canadian Coast Guard Auxiliary, 3 Sep 1999

List of Mayday episodes
(TV series)
Fire on Board; Fire in the Sky – Episode 4, Season 1
A McDonnell Douglas MD-11 operating as Swissair Flight 111 experiences a fire
in the cockpit due to faulty wiring. The pilots divert the aircraft
toward Nova Scotia, Canada with the intent of landing at Halifax Stanfield
International >Airport, but vital systems start failing…

List: Swissair historical McDonnell Douglas MD-11s

Swissair destroyed-after-incident McDonnell Douglas MD-11

McDonnell Douglas MD-11 production list

ABC Evening News for Thursday, Sep 03, 1998
Headline: Canada / SwissAir Flight 111 Crash

Vanderbilt Television News Archive

NBC Evening News for Sunday, Sep 06, 1998
Headline: Canada / Swiss Air Flight 111 Crash / Peggy’s Cove

Vanderbilt Television News Archive

United States District Court for the Eastern District of Pennsylvania:
in re Air Crash near Peggy’s Cove, NovaScotia on September 2, 1998
Memorandum of Law in response to Defendants’ Joint Motion to dismiss claims
filed on behalf of all French and Swiss decedents…

Table of Contents

Swissair stopped flying on 31 March 2002

Farewell Swissair

Halifax Chronicle-Herald

Swissair Flight 111 Archive

Table of Contents

Table of Contents

Table of Contents

Swissair 111 Memorials To Carry Airline Name And Flight Number

News item: 23 July 1999

Jul 23, 1999 — It was announced July 22 that memorials for the 229 people who died in the crash of Swissair Flight111 in the Atlantic off Peggy’s Cove, Nova Scotia, Canada in September1998 will bear the airline’s name and flight number. The memorials will be unveiled on the first anniversary of the crash.
The two memorials will read:
“In memory of the 229 men, women and children aboard Swissair Flight111 who perished off these shores September2, 1998. They have been joined to the sea and the sky. May they rest in peace. In grateful recognition of all those who worked tirelessly to provide assistance in the recovery operations and comfort to the families and their friends during a time of distress.”
The memorials and a marker on navigation maps pinpointing the crash site itself will form a triangle that faces directly out to where the plane went down.
At one site in the beach-side community of Bayswater, a stone wall will list most of the names of Flight111’s crew and passengers. Three family members have asked that their relatives’ names be left off the memorials. About 29coffins of unidentified human remains will also be buried there in a mass grave.
Benches and a monument made out of a boulder will be erected at the other site in Whalesback, a rocky outstretch of land near Peggy’s Cove, where grieving families flocked after the crash.
Both sites will include memorials bearing the text that will be in English and French.
“People wanted to have memorials that are modest,” said Lorne Clarke, head of the memorial committee. “The memorial wording keeps with this concept while remaining honest with historical fact.”
The issue of what to include on crash memorials has become an issue in recent years, with some airlines being accused of trying to deflect negative publicity by leaving their names off monuments.
The Valujet memorial, established after a plane for the discount airline crashed into a Florida swamp in 1996 killing more than 100people, doesn’t mention the carrier’s name.
A memorial for the victims of TWA Flight800 in New York also doesn’t mention the airline, but states it is in memory of the people “who perished aboard flight800.”

CBC Canadian Broadcasting Corporation

Swissair Flight 111 Archive

Sixty stories

CBC, 1998 September 02

Swiss plane crashes off coast of Nova Scotia

CBC, 1998 September 03

The Swissair Disaster

CBC, 1998 September 03

Statement issued by Prime Minister Jean Chretien

CBC, 1998 September 04

Rex Murphy: Peggy’s Cove’s Pain

CBC, (no date)

The Airplane: MD-11

CBC, (no date)

Swissair Disaster: Passenger and Crew List


CBC, 1998 October 17

Engine recovered from Swissair crash

CBC, 1998 October 29

New revelations about cause of Swissair crash

CBC, 1998 November 13

Suspect insulation found in Swissair wreckage

CBC, 1998 November 16

Swissair search to resume

CBC, 1998 November 26

Swissair search resumes

CBC, 1998 December 21

Swissair investigators take a break

CBC, 1999 March 01

Swissair pays compensation to families

CBC, 1999 March 04

Cost of Swissair crash investigation rises

CBC, 1999 March 26

Recovery of Swissair wreckage will resume next month

CBC, 1999 April 09

Three memorials in Nova Scotia for Swissair victims

CBC, 1999 April 17

SwissAir Victims Displeased with Memorial Plans

CBC, 1999 May 06

RCMP Ask Boaters to Respect the SwissAir Exclusion Zone

CBC, 1999 May 12

Swissair flight 1-11 victims’ burial site selected

CBC, 1999 May 13

Premier Defends Swissair Burial Site

CBC, 1999 May 14

Peel officers honoured for role in Swissair Investigation

CBC, 1999 May 26

Pipers sue Swissair

CBC, 1999 May 27

Remainder of Swissair jet debris to be recovered

CBC, 1999 June 02

Swissair memorial plan takes shape

CBC, 1999 July 12

Confusion surrounds Swissair memorial

CBC, 1999 August 28

Families push government for privacy

CBC, (no date)

The Transcript

CBC, (no date)

Fire in the Sky

CBC (no date)

Fire in the Sky
…The investigation of Swissair Flight 111
does not have all the answers about what caused the plane
to crash, but it has raised some very troubling questions
about the contributing factors. It turns out that the
airlines and aircraft manufacturers have had warnings
for over twenty years about unsafe aircraft wiring and
unsafe procedures for dealing with onboard fires, and
they have done precious little about heeding those warnings…

CBC, (no date)

Swissair: Those Left Behind

CBC, (no date)

The Swissair Crash – One Year Later

CBC, 1999 September 01

Swissair burial service today

CBC, 1999 September 02

Victims of Swissair 111 not forgotten

CBC, 1999 September 02

Swissair memorial dedicated

CBC, 1999 September 02

St. Margaret’s Bay water consecrated for Swissair victims

CBC, 1999 September 02

Swissair 111 legacy: safety changes

CBC, 1999 September 03

Swissair legacy improves the way pathologists deal with families

CBC, 1999 September 03

Pathologist at Swissair disaster says compassion necessary

CBC, 1999 September 04

Swissair victims remembered in solemn service

CBC, 1999 September 04

Swissair families meet Nova Scotians

CBC, 1999 September 06

Dredging for Swissair debris to resume

CBC, 1999 September 06

Dredging of Swissair site may uncover more remains

CBC, 1999 September 07

Swissair relatives meet with FAA

CBC, 1999 September 08

Swissair families reject settlement

CBC, 1999 September 17

TV movie about Swissair 111 crash in the works

CBC, 1999 September 18

Swissair offers aid to fishers

CBC, 1999 October 03

Swissair recovery operation over

CBC, 1999 November 02

Swissair exclusion zone lifted

CBC, 1999 November 09

Swissair to replace controversial Mylar insulation

CBC, 1999 December 08

Another Swissair memorial to bury unidentified remains

CBC, 2000 July 05

Swissair president resigns

CBC, (no date)

Frozen in Time: The Swissair Disaster


CBC, (no date)

Frozen in Time: DNA and unidentified human remains


CBC, (no date)

Frozen in Time: Dark Elegy – Shared Grief


CBC, 2000 September 02

Swissair crash remembered

CBC, 2000 November 29

Recommendations from Swissair crash expected

CBC, 2000 December 03

Swissair report to include recommendations

CBC, 2001 March 14

Transport Canada ignores safety recommendations

CBC, 2001 August 07

Swissair investigators focus on aisle lights

CBC, 2001 August 28

New recommendations from Swissair crash

CBC, 2001 September 02

Third anniversary of Swissair disaster marked

CBC, 2001 October 01

Swissair on verge of bankruptcy

CBC, 2001 October 11

Swissair grounds all flights

CBC, 2001 December 10

Pilots’ backup instruments need better placement: report

CBC, 2003 March 27

No Chance In ’98 Swissair Crash

CBC, 2003 March 27

Report clears pilots in Swissair crash

CBC, 2003 September 02

Swissair 5th anniversary marked

CBC, 2003 September 02

The investigation of Swissair 111

CBC, 2004 January 29

World airline woes: Carriers hit financial turbulence

CBC, 2004 June 17

Court hears evidence in Swissair lawsuit

CBC, 2004 June 17

Court reserves decision in Swissair lawsuit

CBC, 2004 July 07

Judge throws out Swissair lawsuit

CBC, 2007 May 21

Last minutes of Swissair crash released on tapes

CBC, 2008 September 01

Aviation industry slow to act on Swissair safety issues
investigators say

…Ten years after Swissair crash, TSB investigators
still pushing for changes to regulations…

CBC, 2008 September 01

N.S. premier honours Swissair victims, work of Nova Scotians

CBC, 2008 September 02

Families mark 10th anniversary of Swissair disaster

Table of Contents

Transportation Safety Board

TSB Official Report on Swissair Flight 111

Published 27 March 2003

Table of Contents

1.0 Factual Information

1.14 Fire

1.6.10 Electrical System

1.9 Communications

1.11 Flight Recorders

2.0 Analysis

3.0 Conclusions

4.0 Safety Action

4.3.3 Aircraft Wiring Issues

5.0 Appendices

Appendix C Swissair ‘Smoke of Unknown Origin’ Checklist

New York Times

Swissair Flight 111 Archive

Sixty stories

New York Times, 1987 March 20

Swissair Orders 6 MD-11’s

New York Times, 1988 June 26

Practical Traveler; How Airlines Pick the Movies

New York Times, 1989 March 17

Delta and Swissair To Form Venture

New York Times, 1989 September 29

Swissair and S.A.S. Announce Pact

New York Times, 1993 May 13

Citing Safety, Airline Curbs CD and Computer Use

New York Times, 1994 September 18

Swissair Plies the Unfriendly Skies of United Europe

New York Times, 1995 September 14

First-Half Losses Wider for Swissair

New York Times, 1996 May 08

Business Travel; A casino operator’s dream: potential gamblers
who may be bored and are unable to walk away

New York Times, 1997 October 29

For many, a fancy chauffeured limousine has been replaced by a sedan and driver.

…Swissair is now equipping its entire long-haul fleet – 16 MD-11’s and
five Boeing 747’s – with video gambling at every seat in all three cabin classes…

New York Times, 1998 September 03

Plane From J.F.K. Crashes Off Canada

New York Times, 1998 September 04

Experts Seek the Cause of Swissair Crash Fatal to 229

New York Times, 1998 September 04

The Crash of Flight 111: List of 229 Was a Kaleidoscope of Nations

New York Times, 1998 September 04

The Crash of Flight 111: A Timeless Fishing Village Is Transformed in a Moment

New York Times, 1998 September 04

The Crash of Flight 111: At Airports, Echoes of Earlier Crash

New York Times, 1998 September 04

The Crash of Flight 111: Focus on Finding Bodies, Not Flight Recorders

New York Times, 1998 September 05

Crew of Swiss Jet Seemed in Control

New York Times, 1998 September 05

Families’ Last, Grim Task Is Just to Identify the Bodies

New York Times, 1998 September 05

In Crash Landings, Ocean Surface Can Be Less Forgiving Than Runway

New York Times, 1998 September 05

The Crash of Flight 111: A Mostly Reliable Plane, But With Flaws in Its Past

New York Times, 1998 September 06

The Crash of Flight 111: Inquiry Shows Jet Crew Went Silent Before Crash

New York Times, 1998 September 06

Pilots Are Sometimes Unprepared for the Hazards of Operating a Smoky Plane

New York Times, 1998 September 06

Mourners of Flight’s Victims, Seeking Solace, Are Drawn to a Lighthouse

New York Times, 1998 September 07

Data Recorder Is Found, Raising Hopes for Clues to Swissair Crash

New York Times, 1998 September 08

Data Recorder Missed Swissair Flight’s Final Minutes, Investigator Says

New York Times, 1998 September 09

Urgent Messages as Swissair Flight Systems Failed

New York Times, 1998 September 10

Clues Found to Fire’s Location on Swiss Jet

New York Times, 1998 September 10

Swissair’s Web Site Inundated Following Crash of Flight 111

New York Times, 1998 September 11

Crash Investigators Focus on Electrical Part

New York Times, 1998 September 12

Flight 111’s Voice Recorder Is Recovered From Sea Floor

New York Times, 1998 September 13

Swissair Pilots Got Bad Data, Officials Say

New York Times, 1998 September 15

Swissair Jet’s Cargo Had Painting By Picasso and Other Valuables

New York Times, 1998 September 16

Both ‘Black Boxes’ Stopped Recording 6 Minutes Before Swissair Jet Crashed

New York Times, 1998 September 17

Swissair Jet Was Holding Museum Gem

New York Times, 1998 September 19

Jet Crash Divers Confront Deep Perils, and Emotions, in Grim Search

New York Times, 1998 September 20

Jet Crash Raises Question: Are Cockpit Crews Large Enough?

New York Times, 1998 September 25

Peggy’s Cove Journal; On Nova Scotia’s Shore, Will Sadness Be Forever?

New York Times, 1998 October 02

F.A.A. Asks, Can Airliners Get Too Old To Fly Safely?

New York Times, 1998 October 15

F.A.A. Recommends Airlines Replace Insulation in Jets

New York Times, 1998 October 16

Jet Insulation Urged by F.A.A. Is Not Ready Yet, Maker Says

New York Times, 1998 October 30

Heat Damage Is Found in Wires of Swissair Video System

New York Times, 1998 November 13

Smoke Risk Prompts F.A.A. to Order Inspections of MD-11’s

New York Times, 1998 November 19

For Air Crash Victims, Solace Comes on Line

New York Times, 1999 January 12

Threat of Fire Leads to Request For Wiring Checks on Planes

New York Times, 1999 May 20

Swissair’s Parent Buys Airline Caterer for $780 Million

New York Times, 1999 August 06

Swissair and Boeing to Split Payment of Damages in Crash

New York Times, 1999 August 12

F.A.A. Will Propose Removing Flammable Insulation From Big Jets

New York Times, 1999 August 22

Ideas & Trends; A Back Door View Of Airline Safety

New York Times, 1999 August 29

New Technology Brings New Layers of Grief

New York Times, 1999 September 03

‘A Bit of Peace’ for Swissair Crash Families

New York Times, 1999 November 13

A Support Group Helps to Repair Lives Shattered by Plane Crashes

New York Times, 1999 December 16

Safety Changes Advised In the MD-11 Jetliner

New York Times, 2000 March 18

’98 Swissair Crash Inquiry Sees Cockpit Map Light as Spark Source

New York Times, 2000 August 26

Smoke Forces Plane Down

New York Times Magazine, 2000 October 15

What became of the money Swissair paid out after the tragedy of Flight 111?

New York Times, 2000 November 19

Professor Scarry Has a Theory

New York Times, 2001 April 03

Parent of Swissair Posts $1.7 Billion Loss

New York Times, 2001 June 15

Stakes in Weak French Carriers Add to Swissair Woes

New York Times, 2001 July 04

Brussels Sues Swissair In Move to Aid Sabena

New York Times, 2001 August 31

Deep in Debt, Swissair to Cut Back

New York Times, 2001 October 02

Much of Swissair Seeks Bankruptcy

New York Times, 2001 October 03

Lacking Cash, Swissair Grounds All Its Flights

New York Times, 2001 October 04

Governments Intervene to Prop Up Ailing Airlines

New York Times, 2001 October 05

Swissair Returns to the Skies After a 48-Hour Halt

New York Times, 2001 October 09

Amid Financial Wrangling, Swissair Gets Half Its Flights Into the Air

New York Times, 2001 October 18

Europe Agrees to Belgian Rescue of Sabena

New York Times, 2001 November 06

Swissair Makes Deal With E.D.S.

New York Times, 2002 March 02

Switzerland: Airline Protects Name

New York Times, 2002 July 13

Their Watchword Efficiency, Swiss Recoil at Air Disasters

New York Times, 2002 November 06

European Airlines Are Profitable, Despite Problems

New York Times, 2003 March 28

Panel Links Faulty Wiring To ’98 Crash Of Swiss Jet

New York Times, 2003 April 16

Travel Slump Imperils Swissair’s Successor

New York Times, 2005 April 02

Fire Risk Found in Some Boeing Insulation; F.A.A. Seeks Substitute

New York Times, 2008 August 13

The Flight 31 Evacuation: An Overreaction?

New York Times, 2008 September 13

Internet in the Sky: Surf but Don’t Call

The nice thing about a long-haul flight is you’ve got time to do a lot of
different things… You can read. You can watch the movie or, on a few airlines,
enjoy live satellite television. You can work, eat, drink or sleep. And now,
thanks to new technology, you can get broadband Internet service on your
laptop… But one thing you may not do is use that Internet hookup for VoIP,
the voice over Internet protocol services provided by companies like Skype…

Table of Contents

CNN Cable News Network

Swissair Flight 111 Archive

CNN, 1998 September 02

SwissAir jet vanishes from radar near Nova Scotia

CNN, 1998 September 03

Swissair plane is missing

CNN, 1998 September 03

Swissair plane crashes off Nova Scotia; survivors reportedly found

CNN, 1998 September 03

Swissair plane crashes off the coast of Nova Scotia; some bodies found

CNN, 1998 September 03

Swissair plane crashes off coast of Nova Scotia; no survivors

CNN, 1998 September 03

229 killed in Swissair crash off Nova Scotia

CNN, 1998 September 03

Stormy seas hamper Swissair recovery efforts

CNN, 1998 September 03

Grieving relatives told of crash details

CNN, 1998 September 03

Swissair offers to fly relatives to crash site

CNN, 1998 September 03

Leaders in AIDS research, Saudi royal among Swissair victims

CNN, 1998 September 03

World leader in AIDS fight dies in Swissair crash

CNN, 1998 September 03

Swissair: Airline has reputation for safety, efficiency

CNN, 1998 September 04

Swissair recovery switches to salvage mode

CNN, 1998 September 04

Swissair crash scene ‘ghastly’

CNN, 1998 September 04

From Europe and New York, grieving families head to crash site

CNN, 1998 September 04

Few clues surfacing in Swissair crash

CNN, 1998 September 04

Swissair mourners head for crash site

CNN, 1998 September 04

NTSB’s quick-response team aids in Swissair investigation

CNN, 1998 September 05

New details emerge of Swissair 111’s last minutes

CNN, 1998 September 06

Divers trying to salvage Swissair ‘black boxes’

CNN, 1998 September 06

Divers find one of Swissair 111’s ‘black boxes’

CNN, 1998 September 07

Swissair flight recorder lacks plane’s final minutes

CNN, 1998 September 07

Navy closing in on second Swissair ‘black box’

CNN, 1998 September 07

Weather helps search for second ‘black box’

CNN, 1998 September 08

Catastrophic electrical fire suspected in Swissair crash

CNN, 1998 September 08

Bad weather delays Swissair search

CNN, 1998 September 09

‘Black boxes’ invaluable to crash investigators

CNN, 1998 September 09

U.S. Navy equipment arrives to aid search for Swissair voice recorder

CNN, 1998 September 11

Divers recover Swissair 111’s cockpit voice recorder

CNN, 1998 September 17

Shattered Flight 111 can’t be reassembled

CNN, 1998 September 18

Undersea fragments may hold clues to Swissair crash

CNN, 1998 November 05

Families of victims of Swissair crash form support group

CNN, 1999 January 11

NTSB urges new inspections of MD-11 jets in wake of Swissair crash

CNN, 1999 January 21

Report: Pilots of Swissair flight disagreed on emergency procedures

CNN, 1999 August 05

Swissair won’t contest liability in crash

CNN, 1999 December 16

NTSB wants fire risk reduced in MD-11 jets

CNN, 2000 December 04

Swissair crash probe wants better firefighting procedures

CNN, 2001 September 24

Swissair to cut 3,000 jobs

CNN, 2001 October 02

Swissair halts all flights

CNN, 2001 October 22

Swissair bailout approved

CNN, 2001 October 23

National pride driving Swissair deal

CNN, 2003 March 27

Report: Electrical fire probably caused ’98 Swissair crash

CNN, 2003 July 10

Hazard in the Skies?
There are new questions being raised right now
about whether in-flight entertainment systems are putting airliners in peril.
In the 1998 crash of a Swiss Air jet, 229 people died. The Canadian
government now concludes that entertainment system wiring may have
caused the fire that led to that disaster. Since then, U.S. airlines have
reported at least sixty cases in which in-flight systems may have
endangered aircraft. Some of the cases involved smoke and fire…
Any time you’re retrofitting older aircraft, putting new wiring in,
putting new electrical equipment in, there’s always an increased risk…
When they find that it hasn’t been done correctly, the penalties
really are not severe enough…

Table of Contents


Swissair Flight 111 Archive

RCMP, 1998 September 17

RCMP establishes DNA patterns for more than 142 victims of Swissair crash

Table of Contents

Air Safety Week

Swissair Flight 111 Archive

Air Safety Week is the world’s most recognized
newsletter on air safety and security issues…
13 February 2004 discussion:

PBS NOVA: Crash of Flight 111, Aviation Crash Investigation

290 stories

Air Safety Week, 1998 September 07

News Briefs
Reports of the crash of Swissair Flight 111 triggered
massive news coverage just as we were going to press…
• Sources relate that the electrical system on this MD-11, delivered new in
1991, was wired principally with an aromatic polyimide tape insulated wire…
This type of wire insulation burns violently when electrical arcing occurs.
When ignited, this type of insulation creates more smoke than several other
types of common aircraft wire insulation…

Air Safety Week, 1998 September 14

The Final Minutes Of Swissair Flight 111

Air Safety Week, 1998 September 14

News Briefs
A bad experience: Polyimid tape insulated wire (Kapton) of the
kind used on the Swissair MD-11 that crashed recently has not performed
well for the U.S. military – so poorly, in fact, that it is being removed…

Air Safety Week, 1998 September 14

Wiring Woes Can Be Predicted, Offering Potential To Prevent
Accidents Caused By Electrical System Malfunctions

…aircraft wiring is a hot topic in the wake of the crash of Swissair Flight 111,
where more evidence is surfacing that the crew was faced with a massive
electrical malfunction, perhaps aggravated by wiring with a record of
substandard in-service durability…

Air Safety Week, 1998 September 14

Proclaimed Reliability & Safety of MD-11 Not Supported by Data

Air Safety Week, 1998 September 21

Industry-wide Assessment of Aircraft Wiring to be Announced Soon

…A massive electrical failure is the scenario now under closest scrutiny by
investigators of the Swissair crash. The aromatic polyimide (Kapton) wiring
on the aircraft, although resistant to burning at lower temperatures, flares
brilliantly under the intense 10,000 degrees F heat of an electrical short circuit…

Air Safety Week, 1998 September 21

Battery Backup Can Prevent Gaps In Data Collection

Air Safety Week, 1998 September 21

Orders for Emergency Vision Equipment Pouring in After Report
of ‘Smoke in the Cockpit’ From Swissair Flight 111

Air Safety Week, 1998 September 28

An Item That May Bear on the Crash of Swissair Flight 111

…Between 1993 and 1995, a number of incidents involving
flame propagation on thermal acoustical insulation blankets
have been reported…

Air Safety Week, 1998 September 28

MD-11 Among Highest With Reported Fuel Dump Problems

Shortly before Swissair Flight 111 crashed, the pilots
were laboring intensely to dump fuel…

Air Safety Week, 1998 September 28

News Briefs
…emergency back-up battery power for
flight data and cockpit voice recorders… problems
with data lost in the crucial moments before the crash…
ValuJet 592, TWA 800, SilkAir 185 and Swissair 111….

Air Safety Week, 1998 October 05

Carriers Commit to Aiding Families of Aviation Disasters

Air Safety Week, 1998 October 05

Swissair-Delta Get High Marks For Disaster Response

Air Safety Week, 1998 October 05

Model-by-Model Wiring Inspections Needed
To Assure Safety of Aging Electrical Systems

Air Safety Week, 1998 October 05

News Briefs
Thermal acoustical insulation: …One, known as
polyethylene terephthalate (PET) more commonly referred to by
the trade name Mylar, resists tearing and is resistant to low heat.
But it also can burn readily in a fully-developed fire. This
type of liner is believed to have been installed in the MD-11
involved in the Swissair crash… The front face of the PET blanket
sample was totally consumed when subjected to the cotton swab test…

Air Safety Week, 1998 October 12

Concerns About Kapton Wiring Raised Two Decades Ago

Air Safety Week, 1998 October 12

All Versions of DC-10 Under Scrutiny for Potential Electrical Fire Problem

Note: The McDonnell Douglas
MD-11, which entered service
in 1990, was a successor to the Douglas
that began commercial service in 1971.

Air Safety Week, 1998 October 12

Smoke in Cockpits and Cabins Causing Weekly Rate of Precautionary Landings

Air Safety Week, 1998 October 19

News Briefs
Batteries not included: Rudolf Kapustin relates that the idea
of back-up battery power for flight data and cockpit voice recorders
(FDRs and CVRs) has been knocked around for twenty years or more…

Air Safety Week, 1998 October 19

Insulation Versus Wiring: Multiple Hull Teardowns?

Air Safety Week, 1998 October 26

Smoke and Fire Awareness Self-Test

Air Safety Week, 1998 October 26

Vulnerability of Avionics Bays To Runaway Fires A Growing Concern

Air Safety Week, 1998 October 26

News Briefs
Safer materials: The MD-11 now infamous as the Swissair
Flight 111 accident aircraft was built with Kapton wiring insulation and
metalized Mylar film on its thermal/acoustic insulation blankets. Since
the Sept. 2 crash, the fire safety of both materials has been challenged
by various sources…

Air Safety Week, 1998 November 02

Entertainment System Electrical Problems Uncommon, But Do Occur

Air Safety Week, 1998 November 02

News Briefs
Precautionary shut-down: The discovery of heat-damaged
wire in the recovered cockpit remains of Swissair Flight 111 prompted
the carrier to announce last Thursday that it was de-activating the
individual in-flight entertainment systems on its fifteen MD-11
and its three B747 jets as a precautionary measure…

Air Safety Week, 1998 November 09

Cause of Electrical Anomalies Two Years Ago Still Eludes Experts
Software, Flight Manual Changes For All 757/767s Coming Early in 1999

…Unlike the electrical failures on Swissair Flight 111, which led to the loss
of all 229 aboard, the Martinair case had a happy ending. With a relief
captain aboard for the long flight, a third crewmember was available
(unlike the case on the Swissair MD-11) to assume from his jumpseat
position part of the intense workload the crew experienced managing the
increasingly erratic pattern of electrical failures… The case is relevant to
some of the controversy surrounding the Swissair 111 tragedy. It took
a 3-man crew to bring the Martinair emergency to a happy conclusion
(in daylight, in good weather, with no smoke in the cockpit or an
out-of-control fire). Just as cockpit voice and flight data recorder
(CVR and FDR) information was lost on the Swissair MD-11, the
power interruptions on the Martinair 767 caused the loss of data and,
after the landing, the was left running for 30 minutes, which erased
all the cockpit conversation for the final critical moments of the flight…

Air Safety Week, 1998 November 09

Barrier Could Enhance Fire Safety on Commercial Aircraft

…The spectacular flammability of Mylar-lined blankets, which may
have contributed to the Sept. 2 crash of Swissair Flight 111, is
believed to have been a major factor in the FAA’s recent announcement…

Air Safety Week, 1998 November 16

Swissair Flight 111 Accident Puts Spotlight on Wiring Practices
Decision to Connect Entertainment System to Essential Electrics Questioned

Air Safety Week, 1998 November 16

Swissair Flight 111 Captain Made The Right Call

Air Safety Week, 1998 November 16

Faulty Installation Causes An Electrical Fire

Air Safety Week, 1998 November 16

An Option for Combating Electrical Fires: The Virgin Bus

…The action of the ADG coming up to speed and assuming its
generator load would automatically kick out all the normal busses.
The aircraft would then be on a stand-alone virgin bus with
about a 65% load of get-home items…

Air Safety Week, 1998 November 23

Cruel Lessons of Aircraft Fires Mandate More, Not Marginal Capability

…He had no idea if it is a false warning (the false alarm rate is
about 160:1), or if a fire is raging down below that could soon burn
through the belly compartment and spread through the aircraft…

Air Safety Week, 1998 December 07

Swissair Coping With Another MD-11 Emergency

Air Safety Week, 1998 December 07

News Briefs
The “grandfathering” policy stands:
At the recent Aircraft Fire & Cabin Safety Conference, considerable
concern was generated among attendees when FAA officials appeared
to be waffling on the issue of “grandfathering” certain types of thermal
acoustic insulation. In mid-October, the FAA announced an accelerated
program to remove blankets featuring metalized Mylar film…

Air Safety Week, 1998 December 14

News Briefs
More Swissair Flight 111 fallout: The FAA issued an
airworthiness directive (AD 98-25-11) Dec. 10 calling on all MD-11
operators to inspect the area around the forward left and right
passenger doors for frayed, chafed wiring. Inspections and any
needed repairs must be accomplished within ten days of the effective
date of the AD, which is Dec. 28th. The situation presents the
potential danger for an electrical fire…

Air Safety Week, 1998 December 21

Danger of Continuous Smoke Not Tested for Certification

…The presence of smoke in a fire emergency also underscores
a fundamental tenet of aviation: to effect an emergency landing,
the pilot must be able to read vital instruments and to see outside.
Yet testing for the worst-case condition remains inadequate…

Air Safety Week, 1999 January 04

“Within Seconds Something Very Serious Must Have Happened”
Swissair’s Chief Safety Pilot Says of Flight 111
Crash Interview Reveals New Details

Air Safety Week, 1999 January 04

Numerous Safety Issues To Characterize 1999

The high-profile crash of Swissair Flight 111 will
bring to the fore a host of topics that Canadian
investigators and their U.S. counterparts must address…

Air Safety Week, 1999 January 18

“Expedited” Action Urged To Fix MD-11 Wiring Safety Deficiencies

Air Safety Week, 1999 January 25

Fall-back System Seen as Means of Bypassing Disabling Electrical Fires

Air Safety Week, 1999 January 25

News Briefs
The Ostriches Anonymous Association, a group
dedicated to promoting aviation safety and risk awareness…
• Aviation Axioms of Oliver Ostrich, If you need an accident
to recognize a flight safety problem, you are part of the problem…

Air Safety Week, 1999 January 25

Catastrophes Start Small
The Swissair MD-11 accident has opened
a lot of eyes about many different aspects of coping with fire in the
cockpit. Of course, the investigation is as yet incomplete but enough
is known for us to make some reasonable assumptions: The pilots were
not sufficiently alarmed at the outset for them to try and rush to land…

Air Safety Week, 1999 February 01

More Action, Less Talk on Cabin Safety Urged

…Cabin fires: A piecemeal approach has been the norm. Fire-blocking
seat fabrics have been introduced, but other cabin materials feature
flammability and smoke or toxic emission hazards that have not been
addressed. “We need look no further than the recent (Swissair) MD-11
tragedy near Halifax to see that a holistic approach to this subject is
needed,” declared Ken Smart, AAIB…

Air Safety Week, 1999 February 01

News Briefs
Going back into the water: Speaking at the conference, Benoit
Bouchard, chairman of the Transportation Safety Board of Canada,
described the TSB’s investigation into the Sep. 2 crash of Swissair Flight 111
as an “extremely complex, multi-layered investigation.” Recovery has been
more difficult than U.S. investigators experienced with TWA Flight 800,
where the wreckage was strewn across a sandy bottom. At Halifax, the
ocean bottom is littered with rocks. Benoit showed a video clip of
investigators literally picking parts out of piles of rocks hauled up from the
bottom. “We don’t yet have what we need to perform a wiring and electrical
system analysis,” he said. Accordingly, divers will resume their efforts in
March, when the ocean surface is calmer…

Air Safety Week, 1999 February 08

“Nasty Threats” Seen In Recent MD-11 Airworthiness Directives

…”The FAA is waking up to the wiring problem,
even though they are officially denying it”…

Air Safety Week, 1999 February 22

News Briefs
In the wake of the Swissair Flight 111 disaster, the
Aviation Consumer Action Project launched a letter to FAA
Administrator Jane Garvey making three sweeping recommendations:
• 1. Immediately restrict MD-11s to flights where they can
make emergency landings within ten minutes.
• 2. Require that all fly-by-wire airliners have manual controls
that will allow pilots to control and land the aircraft in case of
failure of electronic controls, through retrofit and in new production.
• 3. Require fire suppression and detection systems in all parts
of airliners by the end of 1999.
A few observations are in order…
Regarding point #3, ACAP pointed out in its letter to Administrator
Garvey that “current modern airliner designs generally have less fire
detection and suppression than is required in a restaurant kitchen.”

Air Safety Week, 1999 February 22

News Briefs
Observations on institutions: In a recent interview,
consumer advocate Ralph Nader offered a few thoughts on the culture
and performance of the two top agencies charged with safety:
• On the Federal Aviation Administration: “The institutional history of
the FAA is to be very protective and very indentured to the aircraft
manufacturers and the airlines. That’s their culture… So the image
abroad of the FAA as an arms-length regulatory agency with
extraordinary resources and expertise, and that’s not the case.”
Nader described the FAA as “your paradigm captive regulatory agency”…

Air Safety Week, 1999 February 22

News Briefs
Who’s aboard in the event of a crash: Since last October,
all domestic airlines flying overseas and all foreign flag carriers
flying out of U.S. airports have been required to maintain a list of
contact names and telephone numbers for all passengers for speedy
notification in the event of an accident. The list, along with the
passenger manifest, must be submitted to the U.S. Department of State
within one hour after the carrier is aware of an accident…

Air Safety Week, 1999 March 01

News Briefs
Missing pieces of the puzzle: Canadian investigators into
the crash of Swissair Flight 111 plan to send divers back into the waters
off Halifax in an attempt to find the cockpit smoke/electrical switch,
which has various positions allowing the flight crew to turn off one-third
of the airplane’s electrical systems in sequence, as part of the process of
locating the system in which an electrical problem is occurring and killing
the power to that system as a means of stanching an electrical fire.
The final position of the switch can reveal much…

Air Safety Week, 1999 March 08

Swissair Action Sets Precedent for Liability

Air Safety Week, 1999 March 08

Tougher Insulation Blanket Flammability Standards
Could Take a Decade To Implement in the Fleet

Air Safety Week, 1999 March 08

New Recommendations Coming Soon from Canadian Safety Board

Air Safety Week, 1999 March 22

Regulatory Action To Exceed Recent Flight Recorder Recommendations

Air Safety Week, 1999 March 29

News Briefs
Flight data recorders, the sequel: Safety Board Member
George Black pretty much summed up the NTSB’s prevailing frustration
with the history of dilatory FAA responses to pleas for improved
flight data recording capability: “I fail to understand how
something so good can be so sluggishly responded to.”

Air Safety Week, 1999 April 05

Industry Ready to Fill ‘Appalling’ Inflight Recording Gap

Air Safety Week, 1999 April 12

News Briefs
13-minute gap: Canadian investigators announced last
week they are trying to determine the significance of a gap in radio
communications between Swissair Flight 111 and U.S. air traffic
controllers at Boston. After the aircraft was assigned a frequency
change, the Boston Center was unable to contact the airplane for about
13 minutes (although the aircraft was tracked on radar throughout this time).
Eleven minutes after radio contact was re-established, the aircraft was
handed over to Canadian controllers. Because the accident aircraft was
equipped with only a 30-minute cockpit voice recorder, any cockpit
communications, or attempts to transmit on the radio during the
13-minute gap, were recorded over. That is another reason, Canadian
officials declared, they recommended a 2-hour capability for all .

Air Safety Week, 1999 April 19

Airline Industry Can Benefit from Military Onboard Fire Experience

Air Safety Week, 1999 April 19

News Briefs
Emergency inspection: Evidence of a below-deck electrical fire
that melted adjacent thermal-acoustic insulation blanketing prompted the FAA
to order immediate inspections of some 62 MD-11 aircraft. When maintenance
personnel at Santa Barbara Aerospace in San Bernardino, California, opened up
an MD-11 freighter for a maintenance “C” check March 29 they found evidence
that the Kapton wiring had arced. The intense heat had completely melted away
a 60 by 20-inch section of metalized mylar thermal acoustic insulation blanketing.
Kapton wiring and metalized mylar blankets also were installed in the
Swissair MD-11 that crashed last September (in Nova Scotia)…

Air Safety Week, 1999 May 10

News Briefs
Mixing wire types: This item from an internal Boeing document,
a Fleet Issues Summary Report of March 1998, illustrates the kind of wiring
problems that can occur with wiring, even in the relatively protected cabin
area. It concerns chafing and arcing of passenger seat wiring for ACESS
(advanced cabin entertainment and service system), the standard passenger
service/entertainment system offered on the Boeing 747-400:
“…Kapton wiring can chafe, short and arc”…

Air Safety Week, 1999 May 10

Advanced Recorders Can Help Understand and Prevent Accidents

Air Safety Week, 1999 May 17

Safest Pilots, Mechanics and Heart Surgeons Share Common Coping Skills

Air Safety Week, 1999 May 17

Forgetting Precedent the Most Significant Human Error in Aviation

Air Safety Week, 1999 May 24

News Briefs
Media hit: The influence of the press on
aviation safety policy is not new…

Air Safety Week, 1999 May 24

New Statistics Show Need To Improve Air Safety Record

Air Safety Week, 1999 June 07

Immediate Response a Model to Emulate

Air Safety Week, 1999 June 14

Recently Translated German Investigation of Inflight Fire
Underscores Need to Land and Evacuate

Air Safety Week, 1999 June 14

News Briefs
Not off the hook: In its $100 million lawsuit
against Swissair, the manufacturer of the interactive inflight
entertainment system installed in the accident airplane,
Interactive Flight Technologies, declared that the wiring
connecting its system to the accident aircraft had been
exonerated by Canadian investigators of the Flight 111 crash.
The assertion may be a bit premature…

Air Safety Week, 1999 June 21

Modernized Warsaw System Gives Passengers More Legal Clout
New Convention also equalizes liability exposure for carriers

Air Safety Week, 1999 June 21

News Briefs
Seeing through smoke: On June 16th the FAA certified
the Emergency Vision Assurance System (EVAS), manufactured by
VisionSafe Corp. of Hawaii… In the wake of the 1998 crash of
Swissair flight 111, the company’s order book for EVAS has swelled.

Air Safety Week, 1999 June 28

Inflight Fire Procedures Bulletin Sparks Sharp Reactions

Air Safety Week, 1999 July 05

Investigators Plan Electrical Component Tests
In Search for Cause of Swissair MD-11 Fire

Air Safety Week, 1999 July 05

News Briefs
New emergency procedure: In the wake of the Swissair
Flight 111 tragedy, more pilots seem prone to landing quickly in the
event of an inflight electrical fire. For some two months now, pilots
with one major carrier in Germany reportedly have adopted an
unofficial new procedure. It’s called “Zack, Rum, Rein.” Roughly
translated, it means “Quick, (turn) around, land (into the field).”
The procedure is being passed along by word-of-mouth…

Air Safety Week, 1999 July 05

News Briefs
…wire insulation comprises about 40 percent of the
weight of wire, and as a weight-saving measure the tendency in the
industry has been to use the least thickness that will get the job done.
Aircraft wiring insulation can be as thin as four mils, roughly the
thickness of four human hairs laid side by side. This very thin
insulation makes the wire susceptible to chafing and nicking,
exposing the conductor and creating the potential for dangerous
electrical arcing. By one estimate, doubling the thickness of the
insulation probably would not add much more than 100 pounds or
so to the weight of the aircraft while vastly improving durability….

Note (re item above): The wire insulation thickness
of “four mils” (four thousandths of an inch)
is one-tenth of a millimetre.

Air Safety Week, 1999 July 12

Corrections Urged to Safety Inspections

Air Safety Week, 1999 July 12

Near-Tragedy Illustrates Shortcomings in Combating In-flight Fires

Air Safety Week, 1999 July 12

A Terrifying Tale of In-flight Fire

Air Safety Week, 1999 July 19

Safety of Aging Aircraft Electrical Systems
Under Unprecedented Examination

Air Safety Week, 1999 August 02

Cockpit Smoke Brings Widebody Close to Ditching Over Atlantic

Air Safety Week, 1999 August 09

News Briefs
Sniff test: Three weeks before the Sept. 2 crash of
Swissair flight 111, the purser on the same airplane reported a strange
acid-like smell in the cabin after a flight from Zurich to Hong Kong…

Air Safety Week, 1999 August 09

News Briefs
Open to negotiation: Boeing and Swissair announced
last week an agreement to jointly assume responsibility for damage
payments to families of the victims of Swissair Flight 111.
The proposal was announced during an Aug. 5 pretrial hearing at
a U.S. federal court in Philadelphia, Pa. The apportionment
formula was not disclosed, nor was the impact on the various
insurance companies. However, the proposed arrangement is
estimated to cost the insurers somewhere in the range of
$500 million to $800 million… The offer is significant;
it represents the first time that liability has been agreed
upon before legal action has even started, sources say…
The carriers admit nothing but have relieved plaintiffs of
the burden of having to prove negligence, a costly process
that can take years…

Air Safety Week, 1999 August 16

A Brief History of In-Flight Insulation Blanket Fires

Air Safety Week, 1999 August 16

Metalized Mylar Insulation Must Be Replaced

Air Safety Week, 1999 August 16

News Briefs
Not satisfied; go further: The program to replace metalized
Mylar insulation does not go far enough, argues Transport 2000 Canada,
a non-profit multi-modal passenger interest group. With Canadian
passengers exposed to “an unnecessary risk” for the next four years
while the insulation is replaced, Transport Canada, the equivalent of
the U.S. Federal Aviation Administration, should take a number of
additional steps, the group argues. Among them:
• Provide public notice of foreign airlines flying into Canada
that have this type of insulation.
• Develop improved test standards for aircraft electrical wiring…

Air Safety Week, 1999 August 23

News Briefs
A question of timing: …FAA officials suspected
last fall that the metalized Mylar in the Swissair MD-11 that crashed
in Sept. 1998 may have contributed to the flame spread of the
in-flight fire that is widely believed to have caused the crash.
What took the Canadians so long to make their recommendations?
After all, they had expressed their concerns about the wiring on the
MD-11 last December, which led to a flurry of corrective activity…

Air Safety Week, 1999 August 23

News Briefs
Paper weight: Occasionally, one hears that the downside
of adding a particular safety feature to an airplane is the added weight
(for example, the 50-100 lbs. that would be added to the DC-9 by
retrofitting fire detection and suppression equipment in the belly hold).
One industry source recently suggested that such arguments should viewed
in the context of the weight of items provided for the amusement of the
passengers, as opposed to adding to their safety. For example, what
is the total weight of magazines and mail-order catalogues contained
in the seat-back pockets?…

Air Safety Week, 1999 August 30

Safety Concerns Buffet Industry on Anniversary of Crash at Halifax

Air Safety Week, 1999 August 30

Crash Anniversary Marks Significant Improvement In Disaster Response…

Air Safety Week, 1999 September 06

A Pilot Perspective on Maintenance and Safety

Air Safety Week, 1999 September 13

Wires and Fires

Air Safety Week, 1999 September 13

In-Flight Entertainment System Installation Found Deficient

Air Safety Week, 1999 September 20

Competent To Comment
A new checklist is needed for coping with
in-flight smoke and fires along the lines hinted at, but not
endorsed, in Boeing’s MD-11 supplemental bulletin of last June…

Air Safety Week, 1999 September 20

Hazard Posed by Bad Aircraft Wiring Under Congressional Scrutiny

Air Safety Week, 1999 September 20

Major Carriers Agree To Share Post-Crash Costs

Air Safety Week, 1999 September 20

One Tough Test
After the Federal Aviation Administration
announced its new radiant heat and propane flame test for
thermal/acoustic insulation blankets, we received a number of
messages suggesting that this test was not sufficiently demanding…

Air Safety Week, 1999 September 27

Aging Aircraft Conference Focuses on Electrical Systems

Air Safety Week, 1999 September 27

News Briefs
A different approach: Traditionally, the airline
industry has routed wires in bundles, shielding different types
of wires in the same bundle. Raytheon Systems Co. of Indianapolis,
Indiana, offers an approach that replaces bundles with ribbons of wire.
The technology, known as Ribbonized, Organized, Integrated (ROI) wiring,
is considered particularly appropriate for low-voltage, low-current
signals such as those found in current avionics and flight control systems….

Air Safety Week, 1999 October 04

No Longer Valid
More than a year after Swissair Flight 111 crashed…

Air Safety Week, 1999 October 04

Prototype First
…Swissair will change out the insulation
in a prototype effort commencing Oct. 18, 1999, on one of
its MD-11s, with work slated to conclude Sept. 12…

Air Safety Week, 1999 October 04

Significant Relationship
…the industry does not know
how many bare wires are flying today, and on which aircraft…

Air Safety Week, 1999 October 04

Kapton Wire Replacement in Jetliners Could Dwarf Military Efforts

Air Safety Week, 1999 October 04

A Perspective on the Aging Wire Problem

Air Safety Week, 1999 October 04

Thrice Burned
Three fires occurred over a 2-year period…

Air Safety Week, 1999 October 18

Now It Gets Serious
…a wire welded itself to a screw…

Air Safety Week, 1999 October 18

…the circuit breakers in your house
are more advanced than those in commercial aircraft…

Air Safety Week, 1999 October 18

Healthy Circuits Don’t Trip

Air Safety Week, 1999 October 25

New gear
…The upgraded gear Delta is purchasing
does not guarantee a successful outcome in an emergency.
The emergency kit for the pilots of Swissair Flight 111 aircraft
that crashed in 1998 included fullface, one-piece masks and goggles…

Air Safety Week, 1999 November 01

A New Approach to Cockpit and Cabin Fire Safety

Air Safety Week, 1999 November 08

Promising Results
More than 20,000 additional pounds of the
remains of the Swissair Flight 111 MD-11 have been sucked up
from the bottom of the crash site at Peggys Cove, Nova Scotia…
A suction dredge was used in an effort to retrieve more pieces
of the wreckage, especially of the cockpit and forward area
of the airplane…

Air Safety Week, 1999 November 22

…Did the Navy know something about electrical wiring
that was not effectively transferred to commercial aviation?

Air Safety Week, 1999 December 06

Famous First Words
A highly-pertinent example…of hazardous
infringements…and the need for competent and rigorous regulatory
oversight, involves the installation of the interactive in-flight
entertainment network in the Swissair MD-11 that crashed in Halifax,
Canada, Sept. 2, 1998. While the source of the electrical fire has
not yet been determined, the was among the earliest suspects…

Air Safety Week, 1999 December 13

More Wiring Woes

Air Safety Week, 1999 December 20

Severe Environment Electrical Cabling Can Add Durability and Safety

Air Safety Week, 1999 December 20

Three cases of fire or significant heat damage
on MD-11 aircraft have prompted the NTSB to recommend…

Air Safety Week, 1999 December 20

Coincidental Development
…The effort features two
overall thrusts: to assess the hazard posed by wiring
(smoke, overheats, electrical system design, etc.) and
to improve crew capability for coping with in-flight fire…

Air Safety Week, 2000 January 24

Airflow tests
…Fire development is influenced by airflow…
To determine how a fire may have spread…

Air Safety Week, 2000 January 24

Discrepancies Discovered in Visual Inspections
of Aging Aircraft Electrical Systems

…the report did not outline the nature of the 3,000 items,
such as the number or percent involving chafed wire,
inadequately supported wire bundles, inadequate grounding, etc.

Air Safety Week, 2000 January 31

Major Electrical System Modifications Slated for MD-11

Air Safety Week, 2000 January 31

Wire degradation is age related

Air Safety Week, 2000 January 31

More on the MD-11 airflow tests
…As one pilot quipped,
the smell of burning wire insulation may well alert the
cockpit crew to the dismaying fact that the rest of the day
is not likely to go according to plan…

Air Safety Week, 2000 February 07

Six Reasons

Air Safety Week, 2000 February 07

Head In The Sand Award
…Ostriches Anonymous Association…

Air Safety Week, 2000 March 06

Flurry of Actions to Improve Safety of MD-11’s

Air Safety Week, 2000 March 06

If Temped to Reset Circuit Breakers – Don’t

Pilots Union Urges New Policy

Air Safety Week, 2000 March 20

Remove Data Before Impact

Air Safety Week, 2000 March 27

Cockpit Map Light Possible Culprit in Swissair MD-11 Crash

Air Safety Week, 2000 April 10

Electrical arcing – orientation matters

Air Safety Week, 2000 April 17

Safety Board Calls for Cameras in the Cockpit

Air Safety Week, 2000 April 17

Maintenance Errors Appear to Contribute to More Accidents

Air Safety Week, 2000 April 24

Potential In-Flight Fire Events Occur Daily; Many in Inaccessible Areas

Air Safety Week, 2000 April 24

April Shower of Directives Suggests Electrical Design Flaws for MD-11

Air Safety Week, 2000 April 24

Report Falls Short in Assessment of “Supreme Court of Aviation Safety”

Aviation Today

Preliminary Commentary on the RAND Corporation Study:
“Safety in the Skies – Personnel and Parties in
NTSB Aviation Accident Investigations”

by C. O. Miller, Sedona, Arizona
27 March 2000

Air Safety Week, 2000 May 01

Solution to camera controversy?

Air Safety Week, 2000 May 01

Rising Tide of Criminal Prosecutions Threatens
Flow of Vital Safety Information

Air Safety Week, 2000 May 29

Directives to Keep MD-11 Flying Safe to Top the Century Mark

…The avalanche of airworthiness directives far exceeds the
number of directives issued on other airliners, particularly
in the relatively short interval of some 18 months since the
program was launched. The activity is a direct outgrowth
of the September 1998 crash of a Swissair MD-11 in Canada…

Air Safety Week, 2000 May 29

AD’s a Go-Go
A number of questions were posed to the
Federal Aviation Administration about the growing
list of MD-11 airworthiness directives (AD’s)…

Air Safety Week, 2000 May 29

Still looking for a map light

Air Safety Week, 2000 June 05

Burning Blankets: A Chronology of Fire Hardening

Air Safety Week, 2000 June 05

Industry Given Five Years to Root Out and Replace Insulation

Air Safety Week, 2000 June 12

More than first reported

Air Safety Week, 2000 June 12

Airline Given Choice: Reform or Face Incremental Grounding

…threat of corporate death by slow strangulation…

Air Safety Week, 2000 June 12

“Show Cause” Letter Reveals Concern About Internal Controls

You have seven days…

Note: The next item has nothing to do with Swissair 111,
but it is an irresistible gem.

Air Safety Week, 2000 June 12

Props To Jets

Airplanes can be designed to go high and fast or low and slow, but not both…
… Slightly over 40 years ago we began the move from piston engines
and propeller-driven air transports to jets…Cruising speed, altitude
and range were all doubled. Flying time was halved. A miserable
twelve-hour flight in bumpy air across the Atlantic Ocean became a
tolerable six-hour flight in the smooth air of high altitude.
Safety was significantly improved because of the reliability of
the jet engine and the opportunity to fly in a much better weather
regime. Unfortunately, these benefits came at a price. We designed
ourselves into some problems that we never had before. Takeoff and
landing speeds were also doubled along with runway lengths.
As speeds increased, crash survival became significantly more

Air Safety Week, 2000 June 19

Why air crashes are different

Air Safety Week, 2000 June 19

Another perspective on air crashes

…Airline crashes are always big news because they are such rare events…

Note: At the end of the item above, this appears:
For the full text, see the NTSB website:

This text is no longer available there. It has been moved to:

Remarks by Jim Hall, Chairman, NTSB
before the Aviation Safety Alliance Media Seminar
Washington, D.C., April 6, 2000

Air Safety Week, 2000 June 19

Wiring Matters: An Overview of the Aircraft Wiring Issue

…New jets feature more wiring carrying more current.
The cabin area of a new-production jet, for example, features wiring
for such things as in-flight entertainment systems…

Air Safety Week, 2000 June 19

Electrical & Fuel System Problems Dominate
Douglas Aircraft Airworthiness Directives

Air Safety Week, 2000 June 19

Video Cameras in the Cockpits?

…We really don’t have to store the recorded data on the plane
itself. We could electronically dump all those bits and bytes via
satellite or radio and store them any place we like. We could
even rig the system to automatically destroy the data in 24 hours
if no one asks for it. This technology has existed for a number
of years and Boeing will sell it as a maintenance option.
Lauda Air of Austria bought it with their B-767s and it was
very useful in the investigation of their plane that crashed
near Bangkok in 1991. The was never recovered and was
probably stolen by looters who were first on the wreckage scene.
The airplane had already transmitted significant data to the
airline headquarters in Vienna and the Lauda Air representative
brought it with him. Why don’t we do that?…

Air Safety Week, 2000 June 19

Submitted on time
A seven day deadline was met on the seventh day…

Air Safety Week, 2000 June 26

New Technologies Demonstrate Ability to Defeat Aircraft Fires

Air Safety Week, 2000 June 26

Deferred Maintenance: More Attention is Needed to the Safety Implications

Air Safety Week, 2000 July 10

Case in point

…As always in matters electrical, a convoluted complex emergency
occurred. Coincidental multiple warnings won’t always
happen as a result of an arc-tracking incident but might play
“follow the leader” and cause a merry chase as wires
in a packed bundle are torched. Because it can burn through
anything, high temperature arcing has ample scope for mischief…

Air Safety Week, 2000 July 10

Airline leader wanted

…So far in the discussion of aging effect on aircraft wire,
the focus has been on defects/damage that might cause a
short circuit and an arcing event and/or a fire. Damage to
‘signal’ (low energy) circuits is discounted. However, there
are high impedance/high gain circuits that can be disturbed
by very small leakage currents…

Air Safety Week, 2000 July 10

Downsizing the circuit breakers

Air Safety Week, 2000 July 31

Reversal of ‘No Prosecution’ Tradition Could Undermine Air Safety,
Experts Fear
…All truthful statements should be
inadmissible in a criminal proceeding…

Air Safety Week, 2000 August 07

Falling Like Snow

…horrified at seeing “swarf falling like snow” on the wiring…

Air Safety Week, 2000 August 07

Wiring Diagram

The hazard posed by bad wiring increasingly is being recognized…

Air Safety Week, 2000 September 04

Carriers Absorbing Lessons as Swissair 111 Investigation Continues

Air Safety Week, 2000 September 04

Smoke In The Cockpit

Air Safety Week, 2000 October 02

Military Efforts to Cope with Wiring Woes in Aging Aircraft
Promise Relief for Commercial Geriatric Jets

Air Safety Week, 2000 October 09

Documenting His Case

Air Safety Week, 2000 October 09

A “Silver Bullet” Against Arcing

Air Safety Week, 2000 October 09

A More Complete Definition of Aircraft Age

…the wiring was tested only for 50,000 hours…

Air Safety Week, 2000 October 09

Don’t Get Wiped Out

…an active program to develop an arc fault circuit interrupter
suitable for aircraft installation that can deal with ticking faults…
You don’t want to be pulsed by a radar and have all your breakers trip…

Air Safety Week, 2000 October 09

Oral Examination

…Given the problems associated with wiring and electrical systems
in geriatric jets, a number of pertinent questions were suggested
at the recent U.S. Navy-sponsored aircraft wiring working group…

Air Safety Week, 2000 October 09

Stronger Effort Needed to Assure Safety of Aircraft Electrical Systems

…”Is it time to reduce the number of functions in order to reduce the
exposure?” he asked, referring to the proliferation of wiring-intensive
in-flight entertainment systems, power ports for laptop computers, etc.,
which are installed for marketing purposes but which add little to the safety of
the airplane. For example, there are about 26 miles [42 km] of wiring in the
B737 (entered service 1968), and more than 88 miles [140 km] of wiring
in the newer-design B767 (entered service 1982)…

Air Safety Week, 2000 October 09

Regarding electrical system safety, two recent events
illustrate precisely what should not be happening out in the fleet…
one of the most frightening near-crashes in recent memory…
the Captain and First Officer smelled smoke shortly after takeoff…

Air Safety Week, 2000 October 09

Looks Familiar
…There is an aging wire issue here…

Air Safety Week, 2000 October 09

Re-energize at Your Peril

“There is a latent danger in resetting circuit breakers
tripped by an unknown cause, because the tripped condition is
a signal that something may be wrong in the related circuit,”
advises the FAA with bland understatement…

Air Safety Week, 2000 October 16

Aircraft Thermal Acoustic Insulation: An Update

Air Safety Week, 2000 October 16

An Operator’s Survival Guide to Existing and Proposed
Thermal Acoustic Insulation Requirements

…Thermal acoustic blanketing consists of an insulating material
contained inside a form-fitting “film” similar to the way a pillowcase
contains feathers or foam. In a modern jetliner, the number
of such form-fitting bags providing fire (thermal) resistance and
noise (acoustic) reduction can run into the hundreds. There
are some 1,200 fitted blankets in an MD-80 and 3,400 in an MD-11.
The thermal protection takes two forms: resistance to ignition in
the presence of a fire inside the airplane, and resistance to
“burnthrough” in the event of a post-crash fire outside the fuselage;
that is, a fire fed by spilled fuel… The issue lay dormant until
the fatal 1998 crash of Swissair Flight 111. The accident
airplane, an MD-11, was outfitted with metalized Mylar thermal
acoustic insulation film, which can burn when ignited by, say,
the intense heat of electrical arcing. Canadian investigators
found clear evidence of heat damage to the material…
The alarm sounded by the Transportation Safety Board of Canada
galvanized the FAA into action…

Air Safety Week, 2000 October 16

Japanese Carrier Leads the Trend to Put Safety Data on the Internet

Air Safety Week, 2000 October 16

Dramatic turnaround needed
…Perception of the public is that
it took an accident for the FAA to find something out…

Air Safety Week, 2000 October 23

Law of unintended consequences

…After the emergency landing, investigators found four 50-ampere
circuit breakers popped and “several” heavy gage electrical wires
severed and welded together…

Air Safety Week, 2000 October 23

Heavy burden
…as one industry observer quipped, the plating
on this “silver bullet” may not be that thick. Electrical system
design and installation problems, as well as problems associated
with wire insulation type, will still remain…

Air Safety Week, 2000 October 23

Surprise finding
…inspections of six retired aircraft…
were conducted for two purposes… One was to assess the adequacy
of visual inspections. The second was to assess the state of wire in
aged aircraft… In the wire bundles that were disassembled for these
intrusive inspections, “We found a number of wires cut off in the
bundles.” They were not capped, just cut off. “Though not a
degradation issue, the frequency of this finding is worth noting.
We found a lot more than we’d expect”…

Air Safety Week, 2000 November 06

Safety Board Chairman Continues Push for Cockpit Video Recorders

…This recommendation was made because we didn’t have adequate
information about the cockpit environment in several recent major
investigations, including… the Swissair flight 111 investigation.
In each of these investigations, crucial information about the
circumstances and physical conditions in the cockpit was simply
not available to investigators, despite the availability of
good data from the …

Air Safety Week, 2000 November 13

News Briefs
…a cockpit video recorder would have
helped to show the development of smoke and fire,
as well as the instrument displays, in the doomed jet…

Air Safety Week, 2000 November 13

Swarf Catcher
…”Swarf” is the term used to describe drilling chips
and other debris resulting from metalwork that can fall into wire
bundles. The swarf lodged in the wires can grind away under
vibration, abrading insulation and leading to electrical short
circuits and fires…

Air Safety Week, 2000 November 20

Report Cites Inadequacy of ‘Fit and Forget’ Approach to Wiring

…Knowledge about how wire systems age and how they fail is limited…
Wire systems are becoming more complex with increasing computerization
of operations… Wire system maintenance is very expensive…
The report focuses on additional research into such things as
arc fault circuit breakers and advanced, more robust types of
wire insulation – as an example, some materials exhibit a
“Lazarus effect,” in that their mechanical properties
improve dramatically in high temperature conditions…

Air Safety Week, 2000 November 20

Detectable degradation
…as wire ages in service, anomalies
can be detected short of complete loss of function…

Air Safety Week, 2000 December 11

Improved Fire Protection Needed for Airliners

Air Safety Week, 2001 January 08

Lifesaving advice

…concerned about the hazard of resetting circuit breakers more than once…

Note: In the seventh paragraph of the item above, there is a reference to:
FAA information bulletin (FSAW 00-08A)
The elusive Bulletin FSAW 00-08A
does not now appear in the FAA website, but the
New (2000) FAA Bulletin FSAW 00-08
Resetting Tripped Circuit Breakers
is available – a
copy has been archived in Australia.

…There is a latent danger in resetting a circuit breaker tripped by
an unknown cause because the tripped condition is a signal that
something may be wrong in the related circuit. Until it is determined
what has caused a trip to occur, a flight-crew, maintenance, or
airplane ground servicing personnel usually have no way of knowing
the consequences of resetting a tripped circuit breaker.
Resetting a circuit breaker tripped by an unknown cause should
normally be a maintenance function conducted on the ground…

Air Safety Week, 2001 April 30

A Pop Means a Problem

…A popped circuit breaker is telling you that something is wrong –
that there has been a serious electrical event. The old rule of thumb
to automatically try one reset is not prudent… Operator policies
should reflect the new recognition of the inherent hazard in resetting
circuit breakers… ALPA argued that the FAA’s extant policy,
which allowed one reset, should be modified to discourage resets…

Air Safety Week, 2001 January 08

Three amigos
…Experiencing multiple and conflicting electrical
system anomalies high over the Atlantic, the airplane made an
emergency flaps-up landing at Boston’s Logan airport using
standby instruments. It took the full effort of a three man crew
to bring the Martinair emergency to a happy conclusion
(in daylight, in good weather, with no smoke in the cockpit)…

Air Safety Week, 2001 January 15

Aviation Safety: Are We Getting Better or Worse?

Air Safety Week, 2001 January 15

Expanded Service Difficulty Reporting Requirement
Seen as Boon For Safety Analysis

There are more problems with the MD-11 than with other aircraft
of the same vintage… The available data suggests that the problems
associated with the MD-11 are more widespread than the many fixes
mandated for the airplane’s troubled electrical systems…

Air Safety Week, 2001 March 12

Swissair to Undertake Major Modifications to MD-11 Fleet

Air Safety Week, 2001 March 19

Courageous Action
…The MD-11 Modification Plus program
Swissair is undertaking to better fire-harden its MD-11 fleet is
being hailed in some quarters as a courageous action on the
part of an operator that sets a mark for others to emulate…
Swissair has 19 MD-11s…

Air Safety Week, 2001 March 19

Wire System Task Force Expands Scope of Activity

…Required changes to wiring that may be improperly installed,
poorly maintained or eroded by age appear to be years away…
There have been six aircraft electrical fires from various causes in
the past five months, at a cost of two aircrew fatalities and one hull
written off as a loss. These events involve U.S. aircraft only…
These recent events are not a smoking gun, but rather
“cannons firing” to wake up all concerned about the hazard…
Current maintenance practices are not adequate to detect
degraded and damaged wire… No amount of false categorization,
obscure definitions, or the scattering techniques used throughout
this report can diminish the safety of flight issues

Air Safety Week, 2001 March 19

No Detectors, No Departures, Part II

…March 19 is the deadline set three years ago to retrofit all Class D
cargo holds with smoke/fire detection and suppression equipment…

Air Safety Week, 2001 March 26

Hazards Penetrated Supplemental Certification Process

…In-flight entertainment (IFE) systems that cannot be turned off
unless pilots pull circuit breakers must be modified, disconnected
or removed outright… The directives stem from a wider investigative
net cast by the FAA after the fiasco over the installed in
Swissair MD-11 and B747 aircraft. When one of the MD-11s crashed
at Halifax, Canada, in 1998, and burned Kapton wires were recovered
from the IFE, Swissair officials immediately ordered the same IFE
installations disconnected on remaining aircraft. Circuit breakers were
pulled and power cables literally were cut and capped, pursuant to
complete removal at a more deliberate pace…

Air Safety Week, 2001 April 02

Interim Policy

…The IFE (in-flight entertainment) system should be connected to an
electrical bus that does not supply power to airplane systems that are
necessary for continued safe flight and landing… The listing of sins
not to be repeated is contained in FAA bulletin 00-111-160:
Interim Policy Guidance for Certification of In-Flight Entertainment Systems

Air Safety Week, 2001 April 23

Contingency Plan

…What about a more dire scenario, where the pilots face the real prospect
of having to ditch the airplane in the ocean? Not just from engine loss,
but perhaps an even more threatening specter: in-flight fire. The message
now being preached at many carriers (in the wake of the Swissair Flight 111
disaster) is to get the airplane down ASAP, be it over land or water.
But there’s a problem: Flight crews do not train to ditch.
Simulators are not programmed to reproduce a ditching, and aircraft
operating manuals are discreetly silent on the procedures for ditching.
Nothing seems to be written about how to ditch an aircraft even in
the perfect conditions shown on the seat-back emergency cards:
flat, calm water, in daylight (with the implicit assumption that
engines were running and no raging electrical fire was eating the
airplane’s innards). The airplane’s ditching checklist usually provides
a couple of helpful suggestions: land along the swell; aim for a ship…

Air Safety Week, 2001 April 30

More Coming

… MD-11 operators can expect more actions to correct wiring problems
on the aircraft, according to documents recently obtained that lay out the
five-phase action plan formulated by the Federal Aviation Administration
in the wake of the fatal crash of a Swissair MD-11 at Halifax, Canada.
Phase 5C, the last step, is to be launched this coming May, according to
the overall plan; it features nine service bulletins. These documents
may well become mandatory airworthiness directives… The plan reveals
that the FAA determined just three months after the September 1998
Swissair crash that major work was necessary to assure the safety of
MD-11 electrical systems and their installation…

Air Safety Week, 2001 June 11

Modification Plus Program Proceeds

…The first Swissair MD-11 will undergo the carrier’s proposed
“Modification Plus” program during heavy maintenance
next month. Changes include improved smoke detection,
fire fighting, changes to certain wire routing to improve
separation and redundancy…

Air Safety Week, 2001 July 30

Modification Plus ‘A moral obligation’

…At Swissair, we believe we have a responsibility and a moral
obligation to do this for the Flight 111 victims and their families,
and certainly for our customers and crews…

Air Safety Week, 2001 July 30

‘A huge step forward’

Q: In your study in the aftermath of the Flight 111 accident,
you found the problems that occurred in the accident scenario
were not unique to the MD-11.
A: Absolutely true! It would be completely wrong to say,
‘This is only an MD-11 problem…if that is solved we are all happy again.’
That attitude would not be wise and it would not be fair for our crews
and passengers. It is absolutely an airplane problem, whether it’s an
Airbus, a Boeing or a former Douglas model. In every airplane
you have wires, you have computers, and that is why we are going to
study the problem in the other fleets after these modifications…

Air Safety Week, 2001 July 30

Hidden Surveillance Cameras to Help Detect In-Flight Fires
on Swissair Jets

Air Safety Week, 2001 July 30

Regulators Chided for Glacial Pace of Safety Rulemaking

…To cite a few examples: (1) passenger emergency exit rules
took 10 years, (2) flight simulator rules took 13 years, and
(3) a revision to pilot medical standards took 14 years…

Air Safety Week, 2001 August 20

Held forth
…While cruising at 33,000 feet, they suddenly were struck
with a cascading series of electrical failures. They lost the
autopilot, altimeter, engine gauges, navigational displays, and
emergency lighting. They also lost electric horizontal trim.
The only way they could restore power was by resetting the left
generator breaker and physically holding it in place. Manually
lowering the landing gear and flaps, they made an emergency landing…
“This was a successful failure,” recounted Capt. Edwards.
“I had two thoughts: Keep it right side up and get it on the ground.”

Air Safety Week, 2001 September 10

Canadians Call for Tougher Certification Standards

Flammable materials should not be allowed in aircraft construction.
Transport category airplanes are unacceptably vulnerable to the dangers
of in-flight fire the day they leave the factory because of inadequate
standards for determining the fire resistance of many of the materials
used in their construction. Canadian officials investigating the
fatal 1998 crash of a Swissair MD-11 issued a sweeping call for
tougher standards at an August 28 press conference.
“Combustible materials definitely contributed to this crash”…
How those flammable materials were allowed to be used in the manufacture
of the accident aircraft has turned into a major focus of the investigation…
If arcing aromatic polyimide (Kapton) wiring bundles are in contact with
or in close proximity to the flight deck’s stainless steel oxygen lines, you
have essentially the equivalent of an arc welder at work. Temperatures
far in excess of the melting point of most (if not all) alloys of stainless
steel are easily achievable… Because of the many miles of wiring in a
modern airliner and the possibility of a hidden electrical fault quickly
turning into a blazing inferno, the sensible solution MUST BE that the
power should quickly be disconnected from the wire…

Air Safety Week, 2001 September 10

News Briefs
…All power was lost to the flight data and the cockpit
voice recorders (FDR/CVR). As a result, no data was captured for the
final twenty minutes of the flight, which will no doubt complicate
reconstruction of the sequence of events… The need for assured
electrical power, particularly to the CVR, was urged in one of the TSB’s
earliest recommendations from the Swissair Flight 111 investigation;
in that case, nothing was recorded by the FDR/CVR in the last six minutes
of the doomed airplane’s flight, leaving investigators with a “black hole”
of missing data. It appears that, two and half years later, this TSB
recommendation, strongly supported by the U.S. National Transportation
Safety Board (NTSB), has not yet been implemented in the fleet…

Note: In the weeks after 11 September 2001, Air Safety Week
allocated most of its space to security issues such as cockpit doors,
baggage searches, and traveler identification, thus diverting attention
away from aging wiring and in-flight entertainment systems.
That’s why there is only one item here, over the next four months.

Air Safety Week, 2001 November 12

Corporate culture
Start-up carrier JetBlue Airways is among
the minority of airlines to address
safety in its website…

Air Safety Week, 2002 January 14

News Briefs

…”‘Kapton’ wiring should be banned from civil as well as military
aircraft”… Kapton was the general-purpose wiring installed on
the Swissair MD-11 that crashed in Halifax three years ago, and the
Transportation Safety Board (TSB) of Canada recently criticized test
standards used to certify electrical wiring for use in aircraft.
The U.S. Air Force plans to remove Kapton wiring from its fleet of
B-1 bombers, and to replace all Kapton wiring with Tefzel.
Reflecting the concern expressed by the TSB, an internal Air Force
document declared, “Kapton has been identified as a flammable
substance. Electrical wiring reliability will continue to impact
safety and mission reliability.” Accordingly, the Air Logistics
Command “is authorized to substitute Tefzel for Kapton on any
wiring harness they make”…

Air Safety Week, 2002 February 04

Similar Safety Issues Spur Differing Responses In
Commercial And Military Aviation Sectors

… Aromatic polyimide insulation: Sometimes referred to by its trade
name, Kapton, the military services have restricted its use, as in the
U.S. Air Force, removed it from moisture-prone areas, as in the case
of the U.S. Navy, or undertaken costly programs to remove it entirely
from aircraft, as did the U.S. Coast Guard in the case of its H-65
helicopters. The U.S. Army is removing this wire type gradually
from its aircraft to counter a chafing problem. According to the
GAO report, “As of June 2001, aromatic polyimide had been removed
from 1,389 of the 1,523 Blackhawk helicopters in the Army’s fleet.”
Even though aromatic polyimide dominated findings of the Aging Transport
Systems Rulemaking Advisory Committee, the FAA has not mandated its

Air Safety Week, 2002 February 18

News Briefs
…Readers will recall that a Swissair MD-11
crashed in 1998, most likely from an in-flight electrical fire.
The aircraft was equipped with metalized Mylar insulation (which
is being removed and replaced with a more flame- resistant material),
and with aromatic polyimide (Kapton) wiring. Given this wire’s
explosive nature under arcing conditions, the wiring/insulation
combination may be likened to a match and tinder…

Air Safety Week, 2002 February 25

‘Immediate and Aggressive’ Action Needed to Combat In-Flight Fires

…Current training requirements for combating in-flight fires are
inadequate, and aircrews need a means of gaining access to the areas
behind internal panels where fire may be spreading, the NTSB declared.
In this respect, the safety board’s recommendations mirror those of
Capt. Ken Adams. A safety activist for many years, Capt. Adams
participated in the Swissair Flight 111 crash postmortem as lead
investigator for the International Federation of Air Line Pilots’
Associations (IFALPA). The Swissair jet was lost as a consequence
of runaway fire in inaccessible areas behind interior panels…

Air Safety Week, 2002 March 04

Volume of Airworthiness Directives Has Doubled in Past Decade

…Much of this AD activity relates to the MD-11,
as the electrical system alone on this aircraft accounts
for nearly 70 ADs issued n the past two years…

Air Safety Week, 2002 April 08

Study Highlights High Price of Lessons Not Learned from Disasters

…The Transportation Safety Board (TSB) of Canada proclaimed last
year that airliners are unacceptably vulnerable to the dangers of
in-flight fire the day they leave the factory because of inadequate
standards for determining the fire resistance of many of the
materials used in their construction. The TSB’s call for tougher
standards was an outgrowth of its investigation into the fatal
1998 crash of a Swissair MD-11, most probably from a runaway fire
caused by electrical arcing…

Air Safety Week, 2002 April 08

Inaction, Not Lack of Information, Is the Central Certification Problem

Q: Are adequate checks and balances in place for the
Supplemental Type Certificate (STC) process?
A: I do not believe so. The Swissair MD-11 crash in 1998
demonstrates that. Its in-flight entertainment network was installed
in a way that was incompatible with the electrical design philosophy
of that aircraft. But the installation received an FAA-approved STC…

Air Safety Week, 2002 April 15

Simple Suggestion

…A straightforward idea for determining the severity of an in-flight
smoke event – put smoke/fire detectors in the air conditioning ducts.
Locate the detectors in the ducts at the point where the air exits the
air conditioning pack on its way to the cockpit/cabin. With such detectors,
aircrews would have a ready means of determining if you’ve got smoke
coming from the pack. Delta technicians presently are fighting a plague
of in-flight smoke events with their MD-88 fleet. The challenge is to
locate the source of unnerving smoke. “More than 80 percent of our
in-flight diverts [precautionary landings] are caused by smoke from
the air conditioning packs.” If crews had the means to determine which
pack is generating smoke, they could simply shut down the pack…

Air Safety Week, 2002 April 29

Expression of the week

A tolerance of “risk creep” was the telling term used to
describe an inadequate corporate safety culture during a recent
aviation safety symposium… Examples abound of “risk creep”
(as distinct from risk-taking) in the airline industry… One is:
• Hard-to-read, unclear and/or time-consuming checklists
for smoke in the cockpit.

Air Safety Week, 2002 April 22

Universal Standard for Safety Audits in Final Development

Air Safety Week, 2003 January 13

Procedures Proposed to Protect Safety of Long Range Flights

You’re on fire: Consider the danger of in-flight smoke and fire.
The effects can compound rapidly, leading to total loss of control.
In many cases, the time from initial detection of smoke to loss of
the aircraft is in the range of tens of minutes, not the 3-4 hours
to a divert airfield envisioned for ETOPS flights. Because of the
rapidity of dire consequence, following the fatal 1998 in-flight
fire of a Swissair MD-11 pilots throughout the industry were
enjoined to land immediately in the event of smoke and/or fire. ..

Air Safety Week, 2003 February 17

Risky Business
…The ETOPS report does not address a scenario
like the 1998 loss of a Swissair MD-11 from an electrically initiated
fire in the ceiling area of the forward cabin and cockpit.
PRA can illustrate the dependencies among system failures…

Air Safety Week, 2003 February 23

Digital Averaging – The Smoking Gun Behind ‘No Fault Found’

…At testing time, when one would like to know if a connector, crimp,
splice, wire, solder joint, circuit breaker or other connectivity
component is working properly, the unwanted spurious noise that
under the right conditions could precipitate a full-blown system
failure is simply filtered out by the technology and sometimes
even the test programs. Especially in the early developing stages,
digital measurement equipment simply cannot see all of these
age-related failure modes. Technicians and test engineers,
relying on the higher accuracy of digital instruments,
walk away from the problem with a false belief in the safety
and reliability of the systems they are testing…

Air Safety Week, 2003 March 03

Experts Debate Solutions to ‘No Fault Found’ Conundrum

Air Safety Week, 2003 April 07

Compendium of Complacency
TSB’s SR 111 report:
• What was not being done or required before the accident…
• The paucity of progress since the accident…

Air Safety Week, 2003 April 07

Canadian Investigators Decry Lack of Preparedness for In-Flight Fire

Air Safety Week, 2003 April 07

The Investigators Speak

Air Safety Week, 2003 April 14

A Perverse Case of Battery Backup

…The in-flight entertainment network installed in the Swissair MD-11
that crashed in 1998 was not the only one in which pilots could not
completely deactivate the system with a single main power switch…

Air Safety Week, 2003 April 14

That’s Not All, Folks
Independent aviation data specialist John King
has found more than 50 cases of significant system failures, smoke or
fires involving cabin entertainment from 1988-2001, for an average
incident rate of about four per year..

Air Safety Week, 2003 April 21

Precursor Events Point to System-Wide Shortcomings Before Crash

Air Safety Week, 2003 April 21

New Fitting Can Help Fight Hidden Fires

Air Safety Week, 2003 April 28

Pages From History
A 1986 study of cabin air quality and safety by
the National Research Council bears directly on issues of cabin air
quality and in-flight fire discussed recently: “The use of materials
that have high resistance to burning, that will not propagate a flame,
and that will not generate toxic products when subjected to head loads
sufficient to cause currently used materials to degenerate would
constitute a distinct improvement in passenger safety and air quality
in the event of an in-flight, post-crash or landing fire…”

Air Safety Week, 2003 April 28

Conflict Of Interest

Air Safety Week, 2003 April 28

Fire Issues
Excerpts from minutes of the March 26-27, 2003,
meeting in Phoenix of the International Aircraft Systems
Fire Protection Working Group…

Air Safety Week, 2003 May 05

Task Force Backs Training to Improve Aircraft Wiring Safety

Air Safety Week, 2003 June 02

Beyond Conflict Of Interest

Air Safety Week, 2003 June 02

Bad Breakers
…Although circuit breakers are supposed to prevent or
cut off dangerous electrical arcing, it appears that worn and overheating
breakers can themselves become vulnerable to arcing, according to the
NPRM. The result, according to the NPRM, which referred to several
instances, is “smoke and fire in the flight compartment and main cabin.”
This characterization may understate the hazard…

Air Safety Week, 2003 June 09

Cameras Being Deployed on Aircraft to Improve Safety, Security

Air Safety Week, 2003 June 09

Cameras Being Deployed on Aircraft to Improve Safety, Security

…the Transportation Safety Board of Canada has also called
forcockpit video recording as a result of its investigation
into the 1998 crash of Swissair Flight 111…

Air Safety Week, 2003 July 14

Wishful Thinking
…Once is not often, but it may be intolerable.
For example, smoke in the cockpit events – mostly from air
conditioning glitches – rarely cause accidents, but occasionally
– in the case of Swissair Flight 111 – smoke in the cockpit is
the telltale of an electrically stoked fire…

Air Safety Week, 2003 July 28

U.S. Lawmakers Push Plan to Upgrade ‘Black Boxes’

Air Safety Week, 2003 July 28

Setting Standards
for aircraft wiring…

Air Safety Week, 2003 August 04

In the Spotlight Again
…The Airworthiness Directive is just
the tip of the proverbial iceberg of problems with in-flight
entertainment systems… Alex Richman of AlgoPlus Consulting
has compiled from the service difficulty report (SDR) database
at least twelve reports of various problems this year with
in-flight entertainment systems and associated hardwire/wiring.
Given gaps in SDR reporting, the list is probably partial…

Air Safety Week, 2003 September 08

A Complacent Safety Culture Can Kill, Investigation Concludes

…It took the 1998 crash of a Swissair MD-11 to stimulate
the FAA to undertake testing to produce a more demanding
flammability test for insulation blankets…

Air Safety Week, 2003 September 22

In-Flight Fires Wreak Havoc With Systems Reliability

There is nothing like the whiff of something burning to have an
effect on a pilot akin to a jolt of chilled water to the heart…
Fire in an airplane is fundamentally different from fire in a
building on the ground because the airborne occupants cannot
get out. Buildings can be evacuated. Airplanes must descend and
land, oftentimes with fire raging, or smoldering dangerously,
with power to key systems shut off…

Air Safety Week, 2003 September 29

Still Interfering 17 Years Later
Recall those recent reports from pilots
faced with smoke in the cockpit and the inefficient emergency breathing
equipment that muffled effective communications…
Here’s a 1986 incident…

Air Safety Week, 2003 September 29

Time’s Running Out

Air Safety Week, 2003 October 13

Thought Provoking
On the arcing/smoking events involving in-flight
entertainment (IFE) systems: IFE systems mounted on the back of
every seat are going to have planes making emergency landings
with massive electrical problems as soon as those systems have
been in service long enough to have accumulated condensation,
chafing, insulation embrittlement, some maintenance jiggling,
and so forth. And how many of these aircraft in service still
have aromatic polyimide as the general purpose wiring insulation?

Air Safety Week, 2003 October 20

Smoke Triggers More Diverted Flights Than Engine Problems

Air Safety Week, 2003 October 27

Canadian Accident Investigations Take Too Long, Survey Says

Air Safety Week, 2003 December 08

Harmonizing up
…The intent of these regulatory requirements is
to ensure that the same level of protection from the results of
in-flight fires is provided to passengers on Canadian-operated
commercial transport aeroplanes as on those operated by their
U.S. counterparts and expected to be required of European
operators in future. These regulatory requirements
will correct a potentially unsafe condition…

Air Safety Week, 2004 January 05

Current Regulatory Activity

MD-11 electrical deficiencies, again, bringing the number of
electrically-related ADs for the MD-11 series to nearly 90 since
the 1998 crash of a Swissair MD-11…

Air Safety Week, 2004 January 26

Current Regulatory Activity

Fresh from the electrical shop of horrors, DC-10 and MD-11 again.
Since the 1998 crash of the Swissair Flight 111 MD-11 from an
electrically-stoked fire…

Air Safety Week, 2004 February 16

Avalanche of ADs
(AD: Airworthiness Directive) – Speaking
of mandatory corrections to unsafe conditions, more ADs are
coming on the MD-11. Recall that five were issued recently, all
dealing with electrical system problems. These actions are part
of a five-phase “corrective action program” that began shortly
after the September 1998 crash of Swissair Flight 111, an MD-11…

Airworthiness Directives
This database provides you with all Airworthiness
Directives (ADs) issued by the FAA which are still
in effect – some date back to the 1940s…

Air Safety Week, 2004 March 08

Integrated Preparation to Combat In-Flight Fires Still Needed

Air Safety Week, 2004 March 15

Pilots Claim New Checklists Could Compound Emergencies

Air Safety Week, 2004 March 15

The Smoke, Fire and Fumes Checklist Imbroglio

Hard and fast long-winded trouble-shooting checklists
are what helped ensure that Swissair Flight 111 would go down…

Air Safety Week, 2004 March 22

Vulnerability to Uncontrollable Smoke & Fire Can be Reduced

Goglia Receives First Air Safety Week
Aviation Safety Advocate of the Year Award

31 March 2004

Air Safety Week, 2004 April 12

In-Flight Firefighting Guidance Needs Improvement, Experts Declare

Air Safety Week, 2004 April 26

Fuselage Airflow Concept Could Aid in Airborne Fire-Fighting

Air Safety Week, 2004 June 21

Horror Stories Surface From Unheeded Calls For Improved Wiring Safety

…wiring-related accidents and incidents continue to occur apace…

Air Safety Week, 2004 August 02

Varying Views on Video Recorders

…Video imaging has been installed to monitor wiring conditions
in some MD-11 airplanes operated by Swiss International Airlines
(formerly Swissair) in the aftermath of the Swissair Flight 111
electrical fire…

Air Safety Week, 2004 November 22

Study: Design Shortcomings Play A Prominent Role in Accidents

Air Safety Week, 2004 November 22

Significant Regulatory Activity
Hall of Flame:
The MD-11 is center stage of what might be called the “Hall of Flame,”
with more airworthiness directives than any other transport category
aircraft to our knowledge addressing electrical wiring problems and
electrically-stoked smoke and fire threats…

Air Safety Week, 2004 December 13

MD-11 Corrective Action Plan: A Case Study in Reactive Safety

Air Safety Week, 2004 December 20

Report: Regulatory Response to Fire Incident is Too Limited

…fate and fortune discriminate this event from the
deadly outcome involving Swissair Flight 111, which was
downed by fire raging in an inaccessible space…

Air Safety Week, 2005 February 07

Flight Data Analysis: A Process in Progress

After the crash of Swissair 111, it emerged that the MD-11 FDR
(flight data recorder) sourced approximately 250 parameters,
whereas the QAR recorded about 1,500 parameters…

Air Safety Week, 2005 March 14

Deadline To Replace Mylar Insulation Blankets Looms

Air Safety Week, 2005 March 14

Timeline of Insulation Blanket Fires

Air Safety Week, 2005 March 28

A Bit Of History
About 15 years ago the FAA investigated
the concept of adding smoke detectors through the aircraft.
After investigation, the FAA elected not to pursue this approach.
Part of the problem then, and now, is that fire detection devices
average 200 false detections for each valid detection…

Air Safety Week, 2005 April 11

Monitor Can Help Point to Serious Electrical Problems

…A perfect illustration of the problem comes from Swissair Flight 111,
which crashed in 1998 from a runaway electrical fire…

Air Safety Week, 2005 April 11

Background On Blankets
After Swissair Flight 111 caught fire during
flight prior to an emergency landing approach at Halifax in September
1998, killing all on board, the Canadian Transportation Safety Board
found quite quickly that the fire was due in large part to the ease
with which the electrical fire was propagated sight unseen behind
the cabin and cockpit linings…

Air Safety Week, 2005 April 18

The Real Threat
The FAA is refining its tests of thermal
acoustic insulation blanketing, but the terms “arc, electrical,
electric or wiring” do not appear…

Air Safety Week, 2005 April 18

Another Flight Recorder Failure

Air Safety Week, 2005 April 25

Automation: Pilots As Machine-Minders Or As Professional Aviators?

Air Safety Week, 2005 April 25

The Airline Machine-Minder:
Only a Role For Pilots Willing To Subordinate Themselves

Air Safety Week, 2005 July 25

Deployable Recorders

Air Safety Week, 2005 October 17

Minimum Wiring Tolerances Eschewed In Favor of General Principles

Air Safety Week, 2005 October 17

A Brief History of the Debate Over Wire Separation

Air Safety Week, 2005 October 17

Significant Regulatory Activity

… The intent of the proposed action is to enhance the safety of
commercial airliners by improving the design, installation and
maintenance of wiring systems. The document says, “The FAA
believes that traditional ways of addressing wiring are no longer
enough.” Improved awareness of wiring system design and
maintenance will be accomplished through a variety of means.
First, it proposes that certification requirements for wiring
be consolidated… Second, it introduces a new term, electrical
wire interconnection system (EWIS), to acknowledge the fact
that wiring is just one of many components. “The term EWIS
means any wire, wiring device, or combination of these,
including termination devices, installed in the airplane for
transmitting electrical energy”… The rule is an outgrowth
of the TWA Flight 800 and Swissair Flight 111 accidents…

Advisory Circular 25-YY: Development of
Standard Wiring Practices Documentation

“This advisory circular provides guidance for
developing an electrical system standard wiring
practices document for air carriers, air operators…
maintenance providers, and repair stations.”

Air Safety Week, 2005 October 24

Name and Shame

Air Safety Week, 2005 October 31

Significant Regulatory Activity

…This is significant because STCs traditionally have not considered
EWIS as a separate item warranting safety analysis, as evidenced by
the in- flight entertainment system on the Swissair MD-11 accident
airplane that crashed as a result of a runaway electrically-stoked
fire. The wires in that installation were poorly supported and/or
were not integrated into existing bundles, leading to all sorts of
potentially hazardous situations, e.g., chafing, arc tracking, etc…

Air Safety Week, 2005 November 07

Advance Payments to Air Crash Victims’ Relatives Need Revision

Air Safety Week, 2006 July 24

Cloaking the Arc with a Coat of Many Colors

Air Safety Week, 2006 October 02

Nimrod Accident Highlights Common Safety Problems

Air Safety Week, 2006 November 20

Is A Picture Worth A Thousand Lives?

Air Safety Week, 2007 January 08

CRM: The Good, The Bad And The Ugly

…The 1998 Swissair Flight 111 disaster provides a good illustration of
how the prioritization of emergency checklists (and associated restriction
of attention) may cause obvious solutions to be overlooked. In the case
of Flight 111, crew intuition and initiative were, for a major portion
of the developing emergency, subordinated to compliance. The flight
crew’s implementation of an elaborate Swissair check-list procedure
wasted so much time that when they finally understood what they had to
do – land immediately – the window of opportunity had closed.
An uncontrollable in-flight fire constitutes a serious and complicated
emergency. A fire…can propagate rapidly. Time is critical…
The timeline for the Swissair 111 disaster emphasizes the problem with
elaborate checklist procedures…

Air Safety Week, 2007 January 29

Behind Closed Doors

…The investigation revealed a lack of knowledge of the
communications system’s deficiencies under degraded electrical power…

Air Safety Week, 2007 January 29

The End Of Immobilized Cells

…an electromagnetically tight Faraday Cage…In light of these
developments, air rage will assuredly be coming to a seat near you.
Many passengers subjected to obnoxious inflight cell phone
conversations will be tempted to…just Dial M for Murder…

Air Safety Week, 2007 February 12

Make Mine A BLT

…On Oct. 14, 2004, MK Airlines Flight 1602, heading for Spain,
careened off the end of Runway 24 in Halifax Nova Scotia and
burst into flames at around 4:00 a.m., killing all seven aboard…

Air Safety Week, 2007 April 09

Deadly Switches
…pilots are faced with a myriad of switches.
If in the wrong position, these switches can kill…

Air Safety Week, 2007 April 23

The Fire Next Time

…the fire had centered upon the RGCB and RBTB, parts of which
had melted and vaporized. Molten metal had dripped down on the
insulation blankets beneath the panel, causing extensive fire damage…
The failure had obviously occurred within either the RBTB or RGCB…
You may recall that Swissair 111 had had a bus-tie short-out the day
prior to its accident flight, after it had been replaced and rewired
incorrectly… If the fire had broken out mid-Atlantic, a repeat of
Swissair 111 would have been a most likely outcome, given the very
short period in which the extensive N768UA fire damage occurred…
The aircraft was carrying 185 passengers and 20 crew…

Air Safety Week, 2007 May 14

Coffee on the Center Console

…an electrical fire broke out in the cockpit during a flight…
Evidence was earlier found of electrical arcing in the 737’s cockpit
door locking switch solenoid…The pilots couldn’t get a “gear down”
indication after extending the undercarriage… It took them another
circuit to get that sorted out… It’s always interesting when the pilot
comes on and says “we have a problem and I have to put this plane
down as quickly as I can…” Fried electrics do tend to cascade
your emergency into ongoing crises…

Air Safety Week, 2007 May 21

When Air Safety Is Deemed Optional
He can show you the
difference between life and death when thick smoke fills
the cockpit and you can’t even see the flight instrument panel…

Air Safety Week, 2007 May 23

Swissair 111 ATC Tape Recordings to be Released

Air Safety Week, 2007 May 30

Swissair 111 Cockpit Audio Release Sets Precedent

Air Safety Week, 2007 June 04

Safety News In Brief

…A lightweight material made from carbon nanotubes that is stronger
than steel, and conducts almost as well as aluminum, has been unveiled
by Massachusetts Institute of Technology (MIT). It will lead to more
efficient electric power transmission lines, and lighter wiring for aircraft.
Aircraft weight may be reduced significantly by replacing conventional
wiring with nanotube threads…

Air Safety Week, 2007 July 02

Misusing, Confusing and Disabusing the MEL

…In the cruise at Flt Lvl 320, the crew heard a clunk and lost multiple
services and systems. These included all the captain’s flight instruments:
Primary Flight Display, Upper Electronic Centralized Aircraft Monitoring
display, and the Multi-purpose Control and Display Unit. The autopilot
kicked out… The distribution system has an AC Essential Bus (AC ESS)
with all the stuff you’d never want to lose on it, and that’s normally
powered from AC1. It has two DC busbars (1 & 2) powered from AC1
and AC2 via transformer rectifiers. A DC Essential Busbar, powering
similarly vital stuff, normally sucks its power from DC1 via a DC Battery
Busbar (DC BAT). Each ESS busbar supplies an ESS SHED busbar.
Thus, a loss of AC1 kills the AC ESS busbar and the flow-on (or rather,
OFF) effect is the death of AC ESS SHED, DC ESS and DC ESS SHED.
DC1 busbar is also lost but after five seconds it auto-transfers to feed
from DC2 via DC BAT. However, it will not then supply the DC ESS
busbar… Luckily, the Flight Data Recorder just happened to be on the
AC2 busbar and remained powered. It recorded the point at which
AC1, AC ESS and DC ESS had lost power…
The system losses were all caused by the one triggering event…

Air Safety Week, 2007 July 02

On Becoming Electrically Inert: Switches That Kill

…There was no data recorder and the had been overwritten…

Air Safety Week, 2007 July 16

Safety Board Wants FAA to Speed Action on “Most Wanted” List

…The Safety Board and the FAA agree on the need for CVRs that
record a minimum of two hours of audio… Both parties also agree
on the need for a 10-minute independent power source for
(Recorder Independent Power Supply or RIPS) that takes over when
normal power to the CVR is lost. However, this requirement would
only apply to newly manufactured aircraft…

Air Safety Week, 2007 August 06

Safety News in Brief

…inspections have found wiring deficiencies and stapled wiring in
its aircraft. The heavy maintenance company continues to
deny responsibility. The operator will be allowed to continue flying
the aircraft with some of the wiring still stapled after the airline agreed
to regular checks to ensure the emergency lighting was still working…

Air Safety Week, 2007 November 12

New Safety Steps Ordered for Airliner Wiring

…The mandate greatly enhances the safety requirements for design,
installation and maintenance of electrical wiring in new and existing
aircraft… Safety concerns about wiring systems in airplanes…
Swissair Flight 111, an MD-11, crashed into the Atlantic Ocean near
Nova Scotia, Canada, killing all 229 people aboard. Although an
exact cause could not be determined, the presence of resolidified
copper on a portion of a wire of the in-flight entertainment system
cable indicated that wire arcing had occurred in the area where
the fire most likely originated… “We’ve gained enormous
knowledge about aircraft wiring issues over the last decade…”

Air Safety Week, 2007 November 19

Significant Regulatory Activity
737 operators based in the US must now
install new circuit breakers, relays, wiring and switches in the cabin to
give flightcrews the ability to remove electrical power from their
in-flight entertainment systems. The NPRM is based upon prior Service
Bulletins that were produced after an audit of 180 systems on various
aircraft. That audit in turn had stemmed from the TSB of Canada
finding that the Sep 98 crash of Swissair 111 had been related to a
wiring fire and the MD-11’s poorly installed power-hungry IFEN…

Air Safety Week, 2007 December 03

NTSB to Examine Safety Issues Surrounding Cargo Flight Fires

Air Safety Week, 2007 December 12

Safety News in Brief

…The new final rule on wiring safety… The wiring insulation types
aspect was ruled “out of order” from the word go – simply because
it would prove too contentious. Yet it was really what it was all about,
some wiring insulation being proven to be much more risky and life-limited
than others. You don’t set out to have all dogs banned just because
pit-bulls and rottweilers are unpredictably anti-social. However
with wiring, the “system” has declared it all to be anti-social and in
need of strict discipline… so it’s neatly avoided the whole question
of agonizing over dubious insulation types…

Air Safety Week, 2008 January 14

Safety News in Brief
…Although data can pass between the
networks, “there are protections in place” to ensure that the
passenger Internet service doesn’t access the maintenance data
or the navigation system “under any circumstance”…

Air Safety Week, 2008 January 14

Beyond the Black Box

Air Safety Week, 2008 January 21

Boeing Has a Bad Week

…A Qantas Boeing 747-400 lost main power on its descent into
Bangkok, Thailand on Jan. 7 and was forced to land on battery backup.
There were no injuries and no damage to the jumbo jet. Flight QF2 with
344 passengers on board was about 15 minutes from Bangkok when
the highly unusual failure occurred. The Australian Transport Safety
Bureau and Qantas said that the primary power loss was the result
of faulty drainage in the first-class galley, which resulted in water
entering the generator control unit. Water from the blocked drain
collected in a drip tray under the floor. A crack in the tray allowed
the water to leak into electrical wiring, shorting out the aircraft’s
primary power supply…
Qantas is investigating ways to better protect the plane from leaks…

Air Safety Week, 2008 January 28

Safety News in Brief

…Because of limitations of recorded parameters and the arcane
nature of the glitch, UKAAIB investigators were unable to pin down
the exact cause of a major electrical failure aboard a BA A319
enroute to Budapest from Heathrow in 2005…

Air Safety Week, 2008 February 11

NTSB Probing Smoke in Boeing Cockpits

…making an emergency landing after the cockpit filled with smoke…
The NTSB is “very concerned” that airworthiness directives originally
scheduled to be issued as early as September 2004 still have not been
issued. “The Board considers any kind of fire and/or smoke in the
cockpit to be a serious issue that could affect other aircraft systems,
lead to a loss of visibility, provide a distraction, or incapacitate the
crew and possibly lead to an accident…”

Air Safety Week, 2008 February 11

Safety News in Brief

…Two weeks ago a Qantas pilot refused to fly a Boeing 767 from
Sydney after discovering that a galley sink had been blocked with
coffee grounds. On the pilot’s insistence the maintenance staff
checked the plane and are understood to have found the drip tray on
the plane was cracked in exactly the same place as the one on the
troubled QF2 flight into Bangkok. That’s the flight that lost
all its electrics due to water immersion of bus controllers in the
main electrical load center…

(See January 21 item above)

Air Safety Week, 2008 March 17

Upgrades for Aircraft “Black Boxes”

…A new FAA rule requires…that all voice recorders must capture the
last two hours of cockpit audio instead of the current 15 to 30 minutes.
The new rule also requires an independent backup power source for the
voice recorders to allow continued recording for nine to 11 minutes
if all aircraft power sources are lost or interrupted. Voice recorders
also must use solid state technology instead of magnetic tape, which is
vulnerable to damage and loss of reliability…

Air Safety Week, 2008 June 23

Safety & Technology Trends

…EVAS Worldwide says the Gulfstream G650, due to enter service in the
second half of 2012, will have the Emergency Vision Assurance System
(EVAS) as standard equipment. EVAS allows pilots to see in continuous
dense smoke. With EVAS protection included as standard equipment,
the G-650 will be the first factory delivered aircraft to meet
FAA recommended standards for cockpit smoke

The Air Line Pilots Association in-flight fire project report concluded that
there were more than 1,100 in-flight smoke and fire incidents in a ten-month
period, causing 360 emergency unscheduled landings, due to smoke, fumes,
or fire on board aircraft. The numbers of smoke related emergencies
aboard aircraft have continued to rise, numbering about three to four
emergency diversions and landings a day within North America alone…

Air Safety Week, 2008 June 23

Safety & Technology Trends

…AVSI’s Wireless Sensor Networks pProject aims to remove wires from
airplanes, which in turn would make the vehicles lighter. This would help
reduce fuel consumption as well as reduce the costs associated with
manufacturing new aircraft. Additionally, there would be increased
reliability of operational systems and the risk of wire corrosion, loosening
or short-circuiting due to vibration would be eliminated, thus making
air travel safer…

Air Safety Week, 2008 August 11

NTSB Urges Fixes to Airbus Cockpit Displays

…Preliminary findings indicate that a fault occurred in the airplane’s
AC 1 electrical bus, one of the two primary electrical distribution
systems for the airplane, which in turn caused a number of other
electrical busses on the aircraft to lose power. The loss of this
electrical power led to the loss of a number of aircraft displays
and systems… The Board is especially concerned about a failure
under such circumstances because of the increased pilot workload
and potential for crew distraction associated with managing the failure…

Air Safety Week, 2008 August 11

Safety & Technology Trends

…An American Airlines Boeing 757 made an emergency landing and was
evacuated at Los Angeles International on Aug. 5 after indications of
a fire in the passenger cabin… The flight deck crew elected to turn
around after someone smelled smoke in the cabin, but no sign of fire
was found on the jetliner using thermal imaging cameras that scanned
the cabin and cargo hold. The captain elected to declare an emergency…

Air Safety Week, 2008 August 18

American Joins Southwest in FAA Dog House

…Wiring in the wheel well was one area where carriers
failed to comply with airworthiness directives…

Air Safety Week, 2008 August 18

American Says Heated Oil Caused Smoke on Flight

Air Safety Week, 2008 August 25

Surfing the Web While Airborne Now a Reality

Air Safety Week, 2008 September 08

NTSB Provides a ‘Crash’ Course

The NTSB is offering a two-day course on how public relations
personnel can most effectively manage emergency communications
following a major aircraft accident…

Table of Contents

Transportation Safety Board

TSB Official Report on Swissair Flight 111

Published 27 March 2003

Table of Contents

1.0 Factual Information

1.14 Fire

1.6.10 Electrical System

1.9 Communications

1.11 Flight Recorders

2.0 Analysis

3.0 Conclusions

4.0 Safety Action

4.3.3 Aircraft Wiring Issues

5.0 Appendices

Appendix C Swissair ‘Smoke of Unknown Origin’ Checklist


Transportation Safety Board

Swissair Flight 111 Archive

Investigation A98H0003: Swissair Transport Limited
In-Flight Fire Leading to Collision with Water
Peggy’s Cove, Nova Scotia, five nautical miles SW
2 September 1998

TSB Press Release, 1998 September 03

The Transportation Safety Board of Canada is sending investigators
to the site of the accident south of Halifax, Nova Scotia
Involving a Swissair MD-11 flying from New York to Geneva
on the night of 02 September 1998

TSB Press Release, 1998 September 03

Statement by the Chairman of the Transportation Safety Board of Canada
concerning the investigation into the accident south of Halifax
involving a Swissair McDonnell Douglas MD-11
on the night of 02 September 1998

TSB Press Release, 1998 September 11

Cockpit Voice Recorder of Swissair Flight 111 Retrieved

TSB Press Release, 1998 September 15

Swissair Flight Recorders Stopped at the Same Time

TSB Press Release, 1998 September 17

The challenging state of the primary wreckage site and
update on the ongoing investigation of Swissair Flight 111

TSB Press Release, 1998 October 02

Heavy-Lift equipment to join Swissair Flight 111 recovery effort

TSB Press Release, 1998 October 21

About 27% of the aircraft, by weight, has been recovered to date

TSB Press Release, 1998 October 21

Investigation Update A98H0003: Swissair Flight 111

TSB Press Release, 1998 October 22

Estimated that 48% of the aircraft by weight has now been recovered

TSB Press Release, 1998 October 23

The EARL GREY came in today with loose material,
9 nets, 5 containers

TSB Press Release, 1998 October 24

The SEA SORCERESS heavy-lift operation ended today at 1430

TSB Press Release, 1998 October 26

The scallop dragger ANNE S. PIERCE will start tomorrow morning

TSB Press Release, 1998 October 27

Today’s dragging operation took place on the edge of the debris field

TSB Speech, 1998 October 27 1:30pm

Speaking Notes for the TSB Chairman
TSB News Conference, CFB Shearwater

…One day, early in September, more than 2000 individuals
were involved – in some capacity or another – contending
with the wake of Swissair 111…

TSB Press Release, 1998 October 28

The scallop dragger made 18 passes today,
recovered useful quantities of material

TSB Press Release, 1998 October 29

Some of the cockpit wiring and structure shows signs of heat damage,
some of this wiring is associated with In Flight Entertainment system

TSB Press Release, 1998 November 02

There is now close to 200,000 lbs of wreckage recovered

TSB Press Release, 1998 November 04

Fact Sheet on Nose Section Reconstruction Jig
for Swissair Flight 111, MD-11

TSB Press Release, 1998 November 08

The EARL GREY has completed the latest series of ROV inspections
of the debris field – there is still considerable debris

TSB Press Release, 1998 November 11

Dragging operation suspended because of adverse weather

TSB Press Release, 1998 November 17

Examination of wires and wire bundles is continuing,
some of the recovered material shows heat distress

TSB Press Release, 1998 November 20

Approximately 80 per cent of the aircraft by weight
has now been recovered

TSB Press Release, 1998 December 21

About 85% of the aircraft by weight has been recovered
including about 60 % of the forward fuselage

TSB Advisory, 1998 December 22

Safety Advisory Letter issued by the Transportation Safety Board
of Canada to Mr. Bernard Loeb of the National Transportation
Safety Board of the United States
provides information
on MD-11 wiring to that agency, which is the representative
of the State of Manufacture on the Swissair 111 investigation…

TSB Press Release, 1999 January 24

Work continues on the identification, examination, heat analysis,
documentation, and matching of nose section pieces

TSB Press Release, 1999 January 28

Work in Hangar A at Shearwater, Nova Scotia, on the identification,
examination, heat damage analysis, documentation, and
matching of aircraft nose section pieces is continuing

TSB Press Release, 1999 March 05

To date, about 88 per cent of the aircraft structure,
by weight, has been recovered

TSB Press Release, 1999 March 09

TSB Issues Aviation Safety Recommendations for
Flight Recorder Duration and Power Supply

TSB Press Release, 1999 April 08

The research vessel CFAV ENDEAVOUR has been retained
by the TSB for the continuing recovery operation

TSB Press Release, 1999 August 11

TSB issues Aviation Safety Recommendations for Thermal Acoustical
Insulation materials and Flammability Test Criteria

TSB Press Release, 1999 August 27

Between early May and the end of July, aircraft wreckage was
recovered: about 5,100 lbs [2300kg] of wire, portions of the aircraft
skin and interior pieces. Some of the recovered pieces were from
the forward ceiling area, and showed heat damage

TSB Press Release, 1999 November 01

Exclusion Zone at the Swissair 111 crash site has been lifted

TSB Press Release, 1999 November 18

Location of Debris Field

TSB Press Release, 1999 December 15

Swissair Flight 111 Wreckage Recovery Completed

TSB Advisory, 2000 March 02

Aviation Safety Advisory A000008-1:
MD-11 Flight Crew Reading Light (Map Light) Installations

Safety Advisory Letter issued by the Transportation Safety Board
of Canada to Mr. Bernard Loeb of the National Transportation
Safety Board of the United States provides information
on MD-11 cockpit map light installation to that agency…

TSB Advisory, 2000 March 03

Safety Advisory Letter issued by the Transportation Safety Board
of Canada to Mr. Bernard Loeb of the National Transportation
Safety Board of the United States
provides information
on MD-11 cockpit map light installation to that agency, which
is the representative of the State of Manufacture on the
Swissair 111 investigation…

TSB Press Release, 2000 May 24

20 arced electrical wires have been found, analysis of the airflow
testing in the space above the ceiling in the forward section

TSB Press Release, 2000 August 29

Investigation Update A98H0003 Swissair Flight 111 – August 2000

TSB Press Release, 2000 December 04

Interim Aviation Safety Recommendations In-Flight Firefighting

…In the case of SR 111, approximately 20 minutes elapsed from the
time the crew detected an unusual odour until the aircraft crashed,
and about 11 minutes elapsed between the time the presence of
smoke was confirmed by the crew and the time that the fire is
known to have begun to adversely affect aircraft systems…

TSB Recommendation, 2000 December 04

Interim Aviation Safety Recommendations In-Flight Firefighting

…When confronted with an in-flight fire, an aircraft crew must
be prepared to rely solely on their experience and training, and
on the aircraft equipment at hand. Therefore, effective in-flight
firefighting measures should allow an aircraft crew to quickly
detect, analyse and suppress any in-flight fire…

TSB Speech, 2000 December 04

Chairman’s (Benoit Bouchard) speech at the public release of
interim safety recommendations from the investigation
of the crash of Swissair Flight 111

…It has now been 27 months since Flight 111 crashed into the sea
near Peggy’s Cove, taking the lives of all 229 people on board.
We cannot, and will not, forget these people. And, though
their fate was a tragedy that we cannot undo, we can, as part of an
international community, try our best to learn from it – to learn
what we can about what went wrong, and what can be done
to reduce the risk of this ever happening again…

TSB Press Release, 2001 August 28

Aviation Safety Recommendations Material Flammability Standards
Investigation into the Swissair Flight 111 Accident

TSB Speech, 2001 August 28

Notes for Remarks by The Hon. Benoit Bouchard,
Chairperson of the Transportation Safety Board of Canada
at the release of recommendations on materials flammability
standards related to the crash of Swissair Flight 111

…In the case of Flight 111, we faced a puzzle of astounding magnitude.
With the cooperative effort of many people, over two million pieces of
the plane and its components have been brought up from the ocean
floor, and examined by our investigative team. It is a painstaking task.
We know, for instance, that the in-flight fire could have been ignited
by an electrical arc from a wire, but here’s a sobering fact: an aircraft of
this type contains about 250 kilometres of electrical wire, and it would
take only a few millimetres of damage to potentially cause a wire
to fail and spark aflame…

TSB Fact Sheet, 2001 September 01

Aircraft Flight Recorders

…The information from flight recorders is paramount
in determining the sequence of events and understanding
the circumstances leading up to an accident…

TSB Photograph, 2001 September 01

SR Flight 111 – Flight Recorders

Magnetic tape recovered from Swissair Flight 111
Photograph: Magnetic tape recovered from Swissair Flight 111


TSB Fact Sheet, 2003 March 25

Swissair Flight 111 Abbreviated Investigation Chronology

TSB Fact Sheet, 2003 March 27

TSB Background and Fact Sheet

…Approximately 3500 transportation occurrences (accidents
and incidents) are reported to the TSB each year in Canada.
The TSB investigates between two and three per cent of annual
reported occurrences by considering whether an investigation is
likely to lead to reduced risk to persons, property or the environment…
The TSB is the lead agency responsible for investigating the
Swissair Flight 111 accident according to International Civil Aviation
regulations (Annex 13), that assign primary investigative
responsibility for aircraft accidents to the country in which
the accident took place….

TSB Press Release, 2003 March 27

Transportation Safety Board of Canada Releases Final Report
on Swissair 111, Makes Nine Additional Safety Recommendations,
Bringing Total to 23

TSB Report, 2003 March 27

Swissair 111 Investigation Report – Synopsis

TSB Fact Sheet, 2003 March 27

Swissair 111 Investigation Report – Executive Summary

TSB Report, 2003 March 27

Transportation Safety Board of Canada:
Official Report on Swiss Air Flight 111

(Copy archived in Canada)

TSB Report, 2003 March 27

Transportation Safety Board of Canada:
Official Report on Swiss Air Flight 111

(Copy archived in Switzerland) PDF: 32 megabytes

TSB Speech, 2003 March 27

Notes for an Address by Mr. Camille Theriault
Chairman of the Transportation Safety Board of Canada
For the release of the Final Report
of the Investigation into the crash of Swissair Flight 111
World Trade and Convention Centre, Halifax, Nova Scotia

…our investigation took more than four years to complete. Consider
its complexity: millions of pieces of shattered aircraft needed to be
recovered from the sea; of the more than 250kilometres of electrical
wire, much was recovered and it all needed to be identified and
examined; extensive series of flight and laboratory tests had to be
conducted; and, an exhaustive analysis of events – even when little
information existed – needed to be carried out. This accident tested
the investigation team in many different ways. But all challenges
were overcome by their ingenuity. For example, we were able to
retrieve 98percent of the airplane, in terms of weight, despite the
wreckage resting 55 metres [180 feet] down on the ocean floor.
An amazing technical feat. The sheer complexity of this type of
investigation has demanded significant resources. The recovery and
investigation cost approximately $57million. This has been the
largest, most complex safety investigation the Transportation Safety
Board of Canada has ever undertaken…

TSB Speech, 2003 August 21

Notes for remarks by Mr. Charles Simpson
Board Member of the Transportation Safety Board of Canada
to the Air Line Pilots Association – Air Safety Forum
Washington, D.C.

…This year marked the conclusion of the Swissair Flight 111
investigation – the most complex and exhaustive investigation
ever conducted by our organization. In fact, one of the most
complex conducted by any organization. It was a tragic air disaster,
but some good has resulted from our investigation. In total,
23 Aviation Safety Recommendations were made. I’m proud to say
that many improved safety measures are now in effect, such as the
upgrading of flammability standards of aircraft materials and
in-flight firefighting procedures. And, of special interest to pilots,
are the proposed rule changes affecting power sources and recording times…

TSB Speech, 2004 April 28

Notes for an address by Mr. Terry Burtch
Director General of the Transportation Safety Board of Canada
to the International Airline Passengers Association (IAPA)
Annual Conference, Toronto, Ontario

…The crash of Swissair Flight 111 into the waters southwest of
Peggy’s Cove, Nova Scotia resulted in the loss of the 229 passengers
and crew members. Determining the facts about this terrible tragedy
was a lengthy and complex process. Time was needed to sift through
and examine millions of pieces of shattered aircraft recovered from
the ocean floor; as well as the 250 kilometres of electrical wiring –
much of it no longer than an index finger. We also needed to conduct
an extensive array of flight and laboratory tests and analyze the series
of events that led to the plane’s demise as well as work alongside a
wide range of dedicated and determined stakeholders, international
regulators, airline operators, manufacturers, unions. All together,
the investigation spanned five years…

Ten Years Later, Where Are We?

Ten years after the devastating Swissair accident,
further action is still needed to mitigate the
significant risks identified in 18 of 23 recommendations.

It is easy to lose sight of what this is all about.
In the final analysis, it is not about the minutia,
nor the arcane. It is about preserving lives.
It is about the safety of crew and passengers.
And, in this case, it is about the 229 men, women
and children who lost their lives on 2 September 1998.

TSB Speech, 2008 April 29

Canadian Aviation Safety Seminar 2008
Opening Remarks by Jonathan Seymour
Board Member Transportation Safety Board of Canada
at the Canadian Aviation Safety Seminar 2008, Calgary

The second of September this year will mark the tenth anniversary of
the destruction of Swissair 111 off Peggy’s Cove, Nova Scotia; with
the tragic loss of everyone on board – 215 passengers and 14crew.
Late last year, the Board made a conscious decision to mark this
tenth year by placing the investigation and its results in the
context of what has been achieved, what remains outstanding,
what has happened since, and how the identified issues and
safety deficiencies have subsequently developed…
Four categories are used to assess responses:
• fully satisfactory,
• satisfactory intent,
• satisfactory in part and
• unsatisfactory…
We publish our recommendations on our website…

TSB Featured Articles

TSB Featured Articles, 2008 July

This article was published in Wings Magazine, July/August 2008

The Transportation Safety Board
Taking centre stage to advance aviation safety

by Blair Watson
…Some of the more prominent aircraft disasters investigated by the
TSB during the past 18 years include the August 2, 2005 runway
overrun and crash and fire of Air France Flight 358 at Toronto
International Airport, the October 14, 2004 crash of MK Airlines
Flight 1602 at Halifax International Airport, and the crash of
Swissair Flight 111 off the coast near Peggy’s Cove, Nova Scotia
on September 2, 1998… The largest TSB investigation to date
occurred after the crash of Swissair Flight 111; it lasted 4.5 years
and cost $57 million. The McDonnell Douglas MD-11 and its
occupants and cargo sustained an impact force “in the order of
at least 350 g,” breaking apart into millions of pieces, which made
the investigation significantly more difficult. DNA-testing of
human remains was required. For weeks after the accident, debris
washed ashore and was added to what had already been collected.
After the flight data recorder was recovered from the seabed, TSB
investigators discovered that the last five minutes and 37 seconds of
the flight were not recorded because the aircrew had turned off the
airplane’s electrical power in its attempt to isolate and fight the fire.
Reconstructing what happened to SR-111 during its last few minutes
was a major challenge for the investigators. More than 350 specialists
from the TSB, National Transportation Safety Board (U.S.), Federal
Aviation Administration (FAA)(U.S.), Air Accidents Investigation
Branch (U.K.), Boeing, Pratt & Whitney, and other organizations
such as the Nova Scotia Coroner’s Office were involved. Part of
the laboratory work done by the TSB revealed to the surprise of
investigators that the airplane’s thermal insulation blankets,
which had passed an FAA test for fire safety, readily ignited

TSB Featured Articles, 2009 February 9

This article was published in The Hill Times (Ottawa)
Policy Briefing, Transportation & Infrastructure, 9 Feb 2009

Safe Transportation is a Right

by Wendy A. Tadros, Chair, Transportation Safety Board of Canada
…TSB investigators need to learn everything they can and that is why
the Canadian Transportation Accident Investigation and Safety Board
(CTAISB) Act, allows for searches, the seizure of evidence, and the
gathering of human evidence through witness statements and on-board
recordings. The task of assembling physical evidence differs from the
challenge of gathering evidence from individuals who know about the
circumstances of an accident. The TSB takes great pains to explain
that our role is not to find fault, to lay blame or to seek reprisals.
Rather, we are investigating to uncover safety lessons with the aim of
ensuring it will never happen again. As more is understood about
the TSB, those involved almost always feel they can tell investigators
what they know…

TSB Featured Articles, 2009 May

This article was published in
The Journal of Parliamentary and Political Law, v2 n3, May 2009

No Fault, No Blame: Protecting Evidence in
Transportation Accident Investigations

by Wendy A. Tadros, Chair, Transportation Safety Board of Canada and
Allen C. Harding, General Counsel, Transportation Safety Board of Canada
…it’s important to understand the role of the Board. The TSB is an
independent body that investigates selected transportation accidents in
the federal system. The sole purpose of these investigations is to make
transportation safer. The TSB accomplishes this purpose by determining
what happened; why it happened; and what needs to be done to ensure it
never happens again… Three examples will help to explain the key court
rulings in this area. The first relates to cockpit voice recorders, or CVRs.
CVRs allow investigators to understand what was happening in the
cockpit and in turn with the aircraft. Legislation states that it cannot
be knowingly communicated or used in legal, disciplinary or other
proceedings. This protection was designed to ensure crews will continue
to support the recording of their workplace for safety purposes but it is
not absolute. A Coroner or Court may allow for the production of CVR
if it determines “the public interest in the proper administration of justice
outweighs in importance the privilege.” CVR recordings and transcripts
have rarely been released to litigation counsel… The second example
relates to witness statements. Clearly, complete and detailed statements
from witnesses are invaluable in understanding the factors that led to an
accident. Parliament addressed this public policy goal by stating no
person shall knowingly communicate or permit a witness statement to be
communicated. Protections in the Canadian Transportation Accident
Investigation and Safety Board (CTAISB) Act
ensure witnesses can be
forthright with investigators. And, the Board believes, there is a
cumulative effect to honouring these protections thereby ensuring human
evidence will be there for future investigations. This privilege has been
upheld across the country in the courts of British Columbia, Alberta,
the Northwest Territories, Ontario and Nova Scotia…

TSB Featured Articles, 2009 September

This article was published in
Esquire Magazine, September 2009 v152 n3

The End of Mystery

by Chris Jones
…Allan Chaulk joined the TSB in 1999, after beginning his career in
aircraft maintenance. Now his job was to reverse-engineer what he
once did: Instead of figuring out how to keep planes in the sky, he
was charged with explaining why they fell out of it. In September
1998, Swissair 111 crashed off Peggy’s Cove, Nova Scotia, shortly
before Chaulk began his new job, and his first assignment was to
help with the massive effort to reconstruct the plane, an MD-11,
piece by tiny piece. The work had made an impression on him.
In some ways, a plane that hits water can be more damaged than
a plane that hits land, or at least it can be damaged differently.
A plane that crashes into the ground crumples and folds into itself,
the way cars accordion through their impact zones; a plane that
crashes into water usually explodes instead, blown apart from the
inside out by the column of water that surges through the fuselage.
During the Swissair rebuild, Chaulk would lift a small fragment of
wreckage out of the seemingly endless piles in the hangar, identify it,
return it to its original shape, and “fracture match” it back into place.
The puzzle was eventually finished, but not before Chaulk was
repeatedly reminded about the tenderness of our flying machines.
The most robust part of them is frequently the bodies they carry…

TSB Featured Articles, 2009 September

This article was published in Wings Magazine, Sep/Oct 2009 v50 i5

Air Accident Investigation

By Chris Krepski, Transportation Safety Board of Canada
…During the Swissair investigation, TSB investigators found that both
the and a half minutes before impact. Consequently, the lack of quality
data severely hampered our efforts to validate some of the primary
safety deficiencies. This is why the Board made eight flight
recorder-related recommendations, including increasing recording
time and providing independent power sources. While progress is
still required in some areas, the FAA issued new regulations requiring
that by 2012, flight recorders have 2-hour recording capacities,
independent power supplies capable of providing 10 minutes of power
and ensuring that a single electrical failure does not result in the
disabling of both flight recorders…

TSB Recommendations

TSB Recommendation, 1999 March 09

Flight Recorder Duration and Power Supply

TSB Recommendation, 1999 August 11

Thermal Acoustical Insulation Materials

TSB Recommendation, 2000 December 04

In-Flight Firefighting

TSB Recommendation, 2001 August 28

Material Flammability Standards

TSB Photographs

TSB Photo Gallery (no date)

SR Flight 111 – Wreckage Recovery
(28 photographs)

TSB Photo Gallery (no date)

SR Flight 111 – Wreckage Reconstruction
(16 photographs)

TSB Photo Gallery (no date)

SR Flight 111 – Flight Recorders
(13 photographs)

TSB Photo Gallery (no date)

SR Flight 111 – Engines
(3 photographs)

TSB Photo Gallery (no date)

SR Flight 111 – MD-11
(3 photographs)

Note: A Google search on the keywords “Canadian Air Safety Board”
(with the quotes as shown) will turn up some interesting
information about the Canadian Air Safety Board, the
predecessor of the Transportation Safety Board.

Table of Contents

International Federation of Air Line Pilots’ Associations

International Federation of Air Line Pilots’ Associations

IFALPA Air Safety Committee Advisory, 1999 March

Swissair Flight 111 Update

IFALPA, 1999


…part of the debate goes to the fundamental issue
of criminal liability of pilots (CLOP)…

IFALPA Press Release, 1999 September 09

Cockpit Voice Recorders

The New Zealand Parliament today unanimously accepted the principle
that cockpit voice recorders, devices installed in aircraft to provide
a continuous recording of the conversation in the cockpit, must not be
used for any purpose other than accident investigation. The
International Federation of Air Line Pilots’ Associations (IFALPA),
representing in excess of 100,000 pilots in almost 100 countries,
is delighted with this result and commends the New Zealand Parliament
for passing this forward looking piece of legislation and for the
important support it gives for flight safety throughout the region
and the world… This new legislation puts the cockpit voice recorder
outside the adversarial legal system as far as the pilot is concerned.
IFALPA’s desire to protect the cockpit voice recorder should not be
seen, as many have mistakenly claimed, as an attempt by pilots to
seek immunity from prosecution. The Federation has no desire or
policy to protect pilots who are guilty of willful negligence –
other sources of evidence are available if a prosecution is required…

IFALPA, 1999

Aviation Safety & Human Factors

…Professor James Reason has pointed out that one of the
features of organisations with a strong safety culture is
a high degree of open-ness. He has also pointed out that
there must be “A climate in which people are prepared
to report their errors”. Are these statements
true of your airline, of your authority?…

IFALPA, 2000

Better Machines, or Better Humans?

We all make mistakes – after all – to err is human.
But we often seem to forget this when it comes to aircraft pilots,
or so it would seem when one considers the fact that over 70% of
all aircraft accidents are blamed on pilots. We often design
flight deck instrumentation for humans who will not make mistakes; we
seem to expect humans to stop being human when they set foot inside
a flight deck. It is my belief that what we call human error is
actually the negative consequences of normal human behaviour that
is not accounted for in design. In other words, we know that humans
make mistakes and we know the types of mistakes they are likely to make;
therefore, we should design flight decks to accommodate such mistakes…

IFALPA Press Release, 2000 April 26

IFALPA’s 55th Conference: Current Issues…

…Meeting of Global Airline Alliances Pilot Groups
Agreement to work through IFALPA for single level of safety world-wide…

IFALPA Press Release, 2000 August 21

Properly Conducted Aviation Accident Investigations
Contribute to Reducing the World Aircraft Accident Rate

…There are disturbing trends that are seriously threatening the
effectiveness of accident investigations. The first is the
release to the public of information in the immediate aftermath
of an aircraft accident. Expressing the view of the
International Federation of Air Line Pilots’ Associations (IFALPA),
Captain Ted Murphy (President) said that:

“All aircraft accident investigation processes should remain
confidential until the full facts have been determined. The
one exception should be where information of a safety nature
is uncovered which must be made known to other operators or
authorities. Aircraft accidents attract an extremely high
media profile and IFALPA recognises that the media will report
what they understand to be the possible causes of any accident.
However, experience shows us that the type of intense speculation
that has, for example, characterised the reporting of the Concorde
accident rarely, if ever, identifies the real safety issues.
Speculation may have the effect, of making it more difficult for
all the parties involved in the investigation to proceed in a
calm and methodical manner. It also has the unfortunate
effect of identifying (mostly incorrectly) possible errors by
certain groups, thereby making it more difficult for those groups
to co-operate in a non-punitive environment with the official
investigation team. IFALPA believes that the media and the
appropriate authorities must work together to keep reporting
within the bounds of what is responsible, reasonable and
technically rational”…

IFALPA Press Release, 2000 November 06

Statement from the President

…The International Federation of Air Line Pilots’ Associations
(IFALPA) denounces, in the strongest possible terms, the growing
and extremely disturbing trend of apportioning ‘blame’ following
aircraft accidents… Since aviation hardware is now very
reliable the essential elements of such a change in safety culture
must come from a complete understanding of all the factors involved
in an accident and of the chain of events which act as precursors
to the accident. Many are convinced that the free flow of
safety related information is a vital tool for improving operating
standards and can undoubtedly make a very real contribution to
aviation safety. The threat of civil or criminal proceedings
for violations of aviation safety laws and regulations is having a
profound and damaging effect on the flow of precious aviation safety
information which is essential if lessons are to be learned from
accident investigations. IFALPA’s views on this issue are
shared by many other organisations…

IFALPA, 2002

The Aftermath of an Accident or Serious Incident
Actions the Regulator Must Consider Taking

“The intention of the IFALPA panel…is to expose the elected
representatives of the various pilot associations from around
the world to the non-investigative activities that they must be
prepared to cope with following an accident or a serious incident.
Time and time again both airlines and pilot associations
demonstrate an appalling inability to deal with these external
issues. The panel will include a prosecutor, a reporter,
a civil trial lawyer and a regulator. What the attendees
should take away is an appreciation for the need for both
pre-planning and post accident organisation. The task is to
describe what actions the Regulator is likely to take as a result
of the investigation process…

IFALPA Press Release, 2003 March 27

Swissair Flight 111 – Release of Accident Report

…The investigation of this tragic accident by the TSBC
was noteworthy in two principal respects. Firstly, the
complexity and thoroughness of the investigation not only
far exceeded all previous Canadian investigations, it was
unique. Secondly, the unprecedented level of participation
by a multitude of organisations heralded a welcome new
approach by the TSBC. There is no doubt that this approach
contributed significantly to the quality of the investigation
and, ultimately, to the quality of the resulting safety
improvements. The advantages of the additional expertise
and resources contributed by the participants cannot be
underestimated (sic, they mean “overestimated”),
and we hope to see the TSBC and other investigative agencies
make similar or greater use of expertise from all qualified
parties in the future. From the evening of the accident to
the finalisation of this Report, an IFALPA team consisting
of members from AEROPERS (the Swissair Pilots’ Association)
and ALPA (which included members from United States and Canada)
was able to work closely with the investigative authorities
and the rest of the investigative team. IFALPA investigators
witnessed first-hand the unselfish dedication and
professionalism of all persons involved in this investigation.
The work of the Transportation Safety Board, the Armed Forces,
the Royal Canadian Mounted Police and local community
volunteers was truly exceptional…

IFALPA, 2007 May

…Unfortunately, a few years ago we heard Swissair 111
call “Pan, pan, pan. We have uh smoke in the cockpit, uh,
request immediate turn to a convenient place”. Ten minutes
later this was upgraded to an emergency as presumably the smoke
in the cockpit had deteriorated to a very serious situation and
ten seconds later the radio call was “Eleven heavy we start
dump now and have to land immediately”. As we know the CVR
stopped some six minutes prior to the MD-11 impacting the water
and all 229 people on board were fatally injured…

IFALPA, 2008 January

Legal Briefing Leaflet

Legal advice in case of accident, incident or operating irregularity…

IFALPA, 2008

IFALPA Jargon Buster

Glossary of aviation acronyms, terms and definitions

Table of Contents


Swissair Flight 111 Archive

Newsweek, 1995 April 24

How Safe Is This Flight?

…Each plane crash also vividly reminds us
of how vulnerable are – hurtling at 500 miles
per hour, seven miles above the earth, sealed
in a pressurized metal can. Flying requires
faith that the technology is reliable and the
humans won’t make errors – and that faith is
tested anew each time a plane goes down….

Newsweek, 1998 September 14

Death On Flight 111

Smoke Was The First Sign Of Trouble.
Then, A Harrowing Half Hour Later,
The Swissair Jet Crashed Into The Sea,
Killing All 229 On Board. What Happened?

Newsweek, 1998 September 14

Shattered Lives: The Faces Of A Tragic Flight

Newsweek, 1998 October 12

A Descent Into The Depths

…The air-traffic controllers watched helplessly
as their radar screens tracked the MD-11 jet
circling slowly downward toward the Atlantic…

Newsweek, 1998 November 09

Electronic Overload?

…Investigators want to know if a new
computer-entertainment system, recently
installed on Swissair Flight 111, sparked
the mysterious fire that caused pilots
to lose control of the plane…

Newsweek, 1998 November 09

Did Gadgets Go Awry?

Probing Swissair’s Entertainment System…

Newsweek, 2005 December 12

Air Safety: Cockpit Smoke Concerns

Newsweek, 2008 March 17

Why U.S. Airlines Can’t Compete

…”The live-or-die decision is more
quick and brutal in the rest of the world,”
says John Leahy, an American who is
COO for Airbus. “After 9/11, Swissair
filed for bankruptcy on a Saturday and
was liquidated over the weekend”…

Table of Contents

United States Navy

Swissair Flight 111 Archive

United States Navy, 1998 September 10

U.S. Navy assists with recovery of Swissair Flight 111

United States Navy, 1998 September 11

U.S. Navy sends new underwater detection system to Halifax

United States Navy, 1998 September 14

USS Grapple continues assistance to Canadian authorities

United States Navy (no date)

Lieutenant Commander David E. Davis, United States Navy

United States Navy photograph, 1998 September 14

United States Navy photograph, debris recovery operations

Canadian Coast Guard Cutter CCGV Hudson (foreground)
conducts Laser Line Scanning (LLS) operations with the
latest U.S. Navy high-tech underwater search equipment
at the crash site of Swissair Flight 111.

Table of Contents

The Daily Telegraph

Swissair Flight 111 Archive

Daily Telegraph, 1998 September 04

Disaster on the ‘UN airbus’

Daily Telegraph, 1998 September 04

Tears for the victims of Flight 111

Daily Telegraph, 1998 September 04

Aids expert and wife are among the dead

Daily Telegraph, 1998 September 04

Briton died after visiting her daughter

Daily Telegraph, 1998 September 05

Submarine seeks Swissair ‘black boxes’

Daily Telegraph, 1998 September 07

Sub detects Swissair flight black boxes

Daily Telegraph, 2001 June 19

Watchdog tells of risk at airport

…A crash off the Canadian coast involving a Swissair MD11, which killed
all 229 on board, has also been blamed on arc-tracking that slowly deprived
the plane of its power, radio, and controls… The majority of the world’s
passenger fleet contains Kapton wiring, including all Airbuses, most Boeings
built before1993 and the BAe146, three of which are used to fly
the Royal Family and the Prime Minister…

Daily Telegraph, 2001 July 13

Fear for masterpieces

Daily Telegraph, 2001 September 29

Swissair teeters on the brink

…Switzerland does not have any laws that would enable Swissair to
go into a Chapter 11-style position to protect itself from creditors.
If it fails to meet its liabilities it will almost certainly be
forced into bankruptcy….

Daily Telegraph, 2001 October 02

Swissair files for bankruptcy

Daily Telegraph, 2001 October 04

Swiss fury over airline grounding

Daily Telegraph, 2002 November 20

The greatest art should not be moving

…Planes and lorries crash, ships sink. Canova’s Three Graces developed
a crack when it was transported to Madrid in 1998. When a Swiss-Air jet
carrying Picasso’s Le Peintre fell out of the sky off Nova Scotia, that was
the end of the painting as well as everyone on board… Serious damage
during transport is much more frequent than museums admit…

Daily Telegraph, 2006 June 16

Why has Airbus hit turbulence?

…the electrical system was coming under intense scrutiny from the
certifying authorities after a Swiss Air crash in 1998, traced to faulty wiring….

Daily Telegraph, 2007 September 16

The greatest art should not be moving

Table of Contents

Table of Contents

Table of Contents

BAZL Bundesamt für Zivilluftfahrt
Swiss Civil Aviation Authority

Swissair Flight 111 Archive

Bundesamt für Zivilluftfahrt (BAZL)
website (German)

Federal Office of Civil Aviation (FOCA)
website (English)

Bundesamt für Zivilluftfahrt (BAZL)

Correct certification of entertainment system
Swissair’s management responds to the rumors in the Sunday press
Flight Safety became an Alibi Exercise
Authorities only had a few days for approvals

An explosive confession by Swiss aviation authorities who also had to approve the entertainment system of the crashed MD-11: safety is jeopardized because they are under Swissair’s massive pressure. The BAZL’s (Bundesamt fur Zivilluftfahrt, Federal Office of Civil Aviation) aviation inspector Leon Volanthen says it in clear German: “SR 111’s crash has fundamentally changed our relationship with the national airline.” The engineer who is responsible for safe flight equipment in Switzerland, will from now on no longer compromise and will resist requests under pressure – even if this would mean losses and competitive disadvantages for the national airline Swissair. The BAZL confessed yesterday that this has not always been the case…

Hazards Penetrated Supplemental Certification Process

…Two months after the Swissair MD-11 crashed, FAA officials launched a special certification review of the IFE (in-flight entertainment) system installed in the accident airplane. The team found gaps in FAA requirements and procedures to ensure that the IFE installation did not compromise safety. Specifically, the IFE was connected to a flight essential bus, not a cabin bus, and the only way it could be depowered was by pulling circuit breakers. In other words, depowering the cabin bus would not disconnect power to the IFE. As an FAA official said at the time, the arrangement “wasn’t inherently unsafe, although it wasn’t understandable to the flight crew, it wasn’t clear to them in an emergency situation.” Others in the industry have taken a harsher view, saying the special certification review of the Swissair installation reflects “a complete blowout of oversight”… In November 1998 the Swiss Federal Office for civil aviation (BAZL) withdrew the operating permit for the IFE installed on Swissair jets…

Swiss National Aerospace Laboratory, 2003 June

Aviation Safety Management in Switzerland
Recovering from the Myth of Perfection
(pdf) 266 pages
Swiss Federal Department of Environment, Traffic, Energy & Communication (DETEC)…

Over the last five years the Swiss aviation sector has been struck by a number of severe aviation
accidents. The tragic sequence of accidents started with the crash of a SwissAir MD-11, in
Halifax, in 1998. This was followed by a fatal accident with a Crossair Saab 340 near Nassenwil
in January of 2000, and a Crossair Avro 146 RJ 100 near Bassersdorf in November of 2001.
Finally, on July 1, 2002, two large civil aircraft crashed near Üeberlingen (Germany) after a
mid-air collision in airspace, controlled by Skyguide. In the same timeframe the Swiss National
Bureau of Accident Investigation (AAIB) reported various cases of near accidents and the
identification of shortcomings in Air Traffic Control equipment.
These events have led to the perception that there might be structural causes, leading to an
overall adverse safety trend in the Swiss air transportation system.

In response, the Swiss Confederation, represented by the “Department for Environment, Traffic,
Energy and Communication” (DETEC), has commissioned NLR to conduct an extensive
evaluation of the safety of air transport in Switzerland. The main objective of this investigation
is to show, in particular, whether the current structures for ensuring aviation safety within
Switzerland are appropriate (i.e. effective and efficient). In accordance with this objective the
investigation follows a safety management approach, because aviation safety can only be
ensured if it is managed properly…

The main finding of the study is that in Switzerland a number of essential safety management processes and associated responsibilities has been institutionalised such that effective safety
management is not achieved. The study has also established that public air transport remains
extremely safe and Swiss aviation is no exception… Nevertheless, this study has found that the
policy outcome, as reflected in the safety statistics of Swiss aviation over the last decade is
unsatisfactory as the safety performance of Swiss aviation is declining whereas that of the
comparable European states is improving. Where Switzerland was clearly ahead of these states
in terms of safety before the nineties, this lead has been lost. To reverse the negative trend and
to restore the exemplary safety performance of Swiss aviation measures are required.
These measures concern the removal of institutional barriers, and the implementation of a
number of organisational changes at the level of DETEC, FOCA (BAZL) and the AAIB.
Moreover it is required to take a number of national and sector-wide safety initiatives…

This study has shown that the lingering sense of perfection of Swiss aviation safety is no longer
warranted in view of the safety performance over recent years. The study has also established
that many initiatives are being initiated in various orgnisations in Swiss aviation to improve
safety management. For these reasons, this report carries the subtitle “recovering from the myth
of perfection”. It is hoped that the many recommendations of this report will help to restore the safety of Swiss aviation to their previous exemplary levels…

§ 1.1.1 Study motive (page 13)
..The tragic sequence of events started with the crash of a SwissAir MD-11, in Halifax, in 1998… one of the most visible and shocking symptoms of the changing aviation environment in
Switzerland has been the bankruptcy of SwissAir, in 2002…

§ 6 The output of the aviation safety policy –
the role of FOCA [BAZL] aviation safety policy:
§ 6.1 Introduction (page 57)
§ 6.2 Safety Management at FOCA (page 58)
§ 6.2.1 The safety organisation of FOCA (page 58)
§ 6.2.2 The safety management system of FOCA (page 71)
§ 6.2.3 Evaluation of Safety Management at FOCA (page 95)

§ 6.2.1 The safety organisation of FOCA (BAZL) (page 58)
FOCA was founded in 1920, and is a special office of the Federal Department of Environment
Transport, Energy and Communication. FOCA has been reorganised several times to adapt to
developments in the Swiss aviation sector. The most recent reorganisation came into effect in
January 2001. This reorganisation transformed FOCA into a process-oriented organisation… One of the objectives of the reorganisation was to create more clarity in the assignment of tasks and responsibilities within FOCA. Asecond objective was to make FOCA more manageable, creating a small management team of the director, the deputy director to whom all processes report, and a vice-director, to whom all competence centers report. This set-up has proven to be much more efficient than the previous arrangement…

§ Safety Actions (page 79)
As a general impression it can be stated that FOCA is rather active and thorough in their responses to external recommendations or concerns such as the BFU recommendations and the findings of the ICAO audit report. The responses of FOCA (BAZL) to the SR-111 investigation findings are quite comprehensive and reflect an active attitude towards safety action…

§ Regulating the airlines & aircrew (page 88)
…This finding is particularly relevant in view of the SR-111 report that states: “The similar nature of various FOCA audit finding indicates that they concentrated on ensuring that the QA [Quality Assurance] programme had the required elements. The findings tended to identify symptoms, rather than the underlying factors manifested in recurring findings… The FOCA accepted SR Technics’ corrective actions, but made similar findings on subsequent audits.”.

§ Timeliness (page 164)
…The effort involved with these foreign cases varies from full participation, such as with Swissair 111, to very minor involvement…

Footnote 16 (page 164):
This accident occurred near Halifax, Canada on 2 September 1998. While the Canadian Transportation Safety Board therefore led the investigation, a significant effort was made by AAIB [Swiss National Bureau of Accident Investigation] in assisting the Canadian Authorities in accordance with Annex13. The final accident investigation report of Swissair Flight111 was made public in February of 2003, more than four years after the accident date.

Appendix F: Improving safety feedback in Switzerland (page 259)
§ 3. Confidential Incident Reporting (page 261)
§ 3.1. Current situation
…Experience has shown that mandatory reporting is relatively successful at collecting information on technical defects and other incidents, which do not involve the responsibility of reporters. On the opposite side, human errors, even if they are induced for example by wrong cockpit design or complicated procedures, are seldom reported and there is little chance they will surface spontaneously. Knowing that human factors are involved to a certain extent in about eighty percent of the accidents, reporting system providing for the confidentiality of reporters are essential tools for accident prevention. In September 1999, ICAO held an Accident Investigation and Prevention Divisional Meeting in Montreal where aviation safety experts from 83contracting states and 11 observer organisations reviewed the ICAO Standards and Recommended Practices, in particular those of Annex 13. They concluded…

Table of Contents

Journal of AirTransportation

Swissair Flight 111 Archive

Journal of Air Transportation, 2004 January 01

Swissair 111 Human Factors: Checklists and Cockpit Communication

…problems with the MD-11 checklist were uncovered during the TSB’s investigation of the Swissair111 accident. Past research indicates that Flight Officers may have difficulty communicating with captains and that this difficulty increases during times of high stress…

One of the criticisms of the pilots and Swissair culture was an overreliance on checklists. Captain John Nance, pilot, author, attorney, and ABC Television Network safety analyst, believed that Swissair’s culture emphasized the checklist causing the pilots to spend precious time going through a logic tree rather than preparing to land…

More troublesome for the TSB was the location of landing preparations on the checklists. Neither the Swissair nor the McDonnell-Douglas Smoke of Unknown Origin Checklist stated that preparations for an emergency landing should be considered immediately. In fact, landing was the last item on the checklist. With Swissair111, the TSB found that even if landing had been first on the list, the aircraft would not have had enough time to land safely at Halifax. Also, as noted above, the pilots did begin preparations for landing before initiating any checklists. While inconsequential for Swissair111, however, placement on the checklist could endanger future flights. The Smoke of Unknown Origin Checklist could take more than 30minutes to complete…the TBS warned that for ongoing in-flight fires 30minutes may be too long…

The MD-11 checklists and the smoke switch used in the procedure were developed to replace the multiple steps a flight engineer carried out for many years on the DC-10. While it is true that the procedures and the development of a single switch in some respects simplified smoke troubleshooting, it also placed the workload previously handled by three crew members onto the shoulders of only two crew members…

There is one final note on checklists. Checklists and simulator training tended to reinforce the idea that actions taken by pilots would result in the smoke quickly dissipating. The premise was that isolating the source could kill potential ignition sources. In the case of Swissair111, the fire was fully realized by the time the smoke appeared in the cockpit. The insulation was already on fire, and eliminating the initial ignition source would have been inconsequential. Starting a checklist immediately would have had no effect. The possibility of an ongoing fire was not emphasized in the checklists…

Subordinate crewmembers can be conditioned to limit their speech after encountering insensitive or intimidating captains… FOs have a difficult time both deciding the captain has made an incorrect decision and choosing the correct time to question that decision. An FO may be concerned that the correction will be interpreted as a challenge to the captain’s authority…

Tarnow illustrated these four elements, including excessive obedience and hesitant communications, using an aircraft accident CVR transcript. Finally, Tarnow concluded that excessive obedience may cause as many as 25% of all airplane accidents…

One of the most controversial moments in the flight came when the aircraft changed course away from Halifax and out to sea to dump fuel. The TSB emphasized in the TSB Final that the pilots did not know, and could not have known, how far the problem had already developed… Multiple failures are extremely improbable considering the highly automated and redundant systems found in modern passenger aircraft. They do happen, however, as illustrated by Swissair111. While the checklists did not play a role in the outcome of Swissair111, conflicts did arise between two of the checklists. This, along with the placement of emergency descent considerations on the checklists, indicates why it is in the aviation industry’s best interest to standardize and rationalize checklists and checklist procedures…

The TSB preliminary summary of the CVR transcript was paraphrased and formed the basis of a WSJ (Wall Street Journal) article, and the conclusions of the article were published in newspapers and magazines around the world. The TSB’s Swissair111 final aviation accident report from the TSB received much less press attention…

Journal of Air Transportation, 2006

Another Approach to Enhance Airline Safety:
Using Management Safety Tools

…Historically, the U.S. Federal Aviation Administration (FAA)
is responsible for fostering and encouraging civil air commerce
and simultaneously auditing aviation safety. However, the
FAA’s “dual-mandate” responsibility has resulted in
criticism in terms of the lack of a sufficient ability to
accomplish safety surveillance… despite a tightened airport,
security, aircraft accidents that endanger aviation passengers
still occur periodically…

Table of Contents

U.S. News & World Report

Swissair Flight 111 Archive

U.S. News & World Report, 1996 December 23

Flying? Consider the Odds: As gambling fever hits the friendly skies…

…Ready or not, gambling fever has reached the friendly skies.
Foreign carriers like Swissair, British Airways, Singapore Airlines
and Alitalia are currently pouring tens of millions of dollars into
state-of-the-art, personalized video screens, which will offer keno,
slots, blackjack, poker and other games. Later this month, Swissair
plans to unveil in-flight gambling on its long-haul flights from Zurich…

U.S. News & World Report, 1998 September 14

The Crash of Flight 111: Smoke in the cockpit, then calls for help

…Swissair moved quickly to deal with the relatives of passengers in the
crash. Forty specially trained employees worked with family members.
Officials held frequent briefings. The airline flew survivors to Halifax…

U.S. News & World Report, 1998 September 28

Checking Up on Kapton: Airplane wiring is a source of suspicion

…When the wire is subjected to chafing, vibration, and moisture, the
insulation may crack, allowing the current to jump to other wires in
the bundle, which become fuel for a fire. The Navy and Air Force
no longer use Kapton as a primary wire insulation…

U.S. News & World Report, 1998 October 18

Swissair Crash Sparks Change

…Although the cause of the Swissair crash has not been pinpointed, experts
suspect that metalized Mylar insulation shrouding electronic equipment in the
Swissair MD-11 jet may have been set ablaze by short circuit… The same
insulation has been implicated in at least three earlier aircraft fires…

U.S. News & World Report, 2001 December 23

Shrinking a Disaster

…summoned to Kennedy airport after the crash of Swissair Flight 111…

Table of Contents

Other (miscellaneous)

Swissair Flight 111 Archive Aviation Online Magazine (date not known)

Aircraft: The Burning Issue Of Aging Wire

…wiring faults may have killed hundreds more in the crash of TWA Flight 800
in July 1996 and Swissair Flight 111 in September 1998. Every airliner has
hundreds of kilometers of wire and more is being added to support sophisticated
passenger entertainment systems. All wire deteriorates to some degree and
much of it is not accessible for inspection. Slowly, ever so slowly the aviation
industry is acknowledging that a hazard exists. Finding remedies will take
much longer… Aging wire concerns are supposed to be addressed jointly by
manufacturers, airlines and regulators. The first two may not be keen to probe
deeply because of horrendous cost implications if something is seriously wrong.
And regulators around the world are being downsized, outsourced and stripped
of technical expertise. The US Government watchdog, the General Accounting
Office recently found that FAA’s inspection initiatives were a shambles…
Something else has changed. Whereas professionals in private resolved
aging structures, aging wire is getting the full glare of the Internet.
A site sponsored by the widow of a Swissair victim, provides more technical
data than any person can digest. She says she is spending her “blood money”
pay-out to ensure informed public debate…

Index: Aircraft Electrical Fire Articles


The Windsor Star, 2008 August 30

Swissair probe delay sparks safety concerns

A decade after Swissair Flight 111 crashed off the coast of
Nova Scotia, the Transportation Safety Board of Canada said
more work needs to be done to satisfy the safety deficiencies
identified in the 4½ year investigation into the accident…

Ottawa Citizen, 2008 September 02

N.S. marks 10 years since Swissair crash

Truro Daily News, 2008 September 02

10th anniversary of Swissair plane crash marked in Nova Scotia

CTV News, 2008 September 02

Families remember victims of Swissair Flight 111

European Business Forum, (no date)
Communicating in a Crisis
…When unexpected events take them by surprise, most executives’ immediate
reflex reaction is one of “shock and defensive retreat”. Quickly pushing
emotions aside and immediately acknowledging that a problem exists remains
the right thing to do. The inability of top management to grasp the outside world’s perception of a problem is often the major trigger of poor crisis management…
Despite all precautions taken to prepare for a major crisis, unexpected events may
happen… This is where corporate executives find themselves most vulnerable.
When Swissair planes were grounded in various countries in 2000 because of the
company’s imminent bankruptcy, airline executives were severely criticised by the
media for leaving thousands of stranded passengers to fend for themselves.
Swissair executives perceived this crisis as unfair (this scenario was not part of
their “crisis manual”) and were too reactive. The situation was poorly managed
and Swissair’s reputation was severely damaged…

Computer-Related Incidents with Commercial Aircraft

Cruel Hoax Perpetrated on the Victims of Swissair 111

Wiring not problem – safety expert

Fire in the Sky


Feds Urge MD-11 Wiring Inspections
Evidence of Kapton wire arcing found


Swissair Timeline, Incorporating

Some more detailed SR111 Background for you


It is a World-Wide Wiring Problem


Wiring Flaw May Have Nullified Pilot Action

Descriptions of High-Temperature Aircraft Electrical Wire Types


The FAA’s Five Percent Solution


U.S. Airlines’ “Handoffs” Raise Safety Concerns:
Foreign Partners Come Under Scrutiny

Every day, thousands of Americans board planes holding a ticket imprinted
with the name of a familiar U.S. airline, but take off in a jet operated by an
unfamiliar foreign carrier. That means some passengers unwittingly
fly on airlines with safety records that fall short of standards set
in the United States and Europe…

Crash Sparks Fear, Search for Safer Flight


SR111 Emergency Procedures

… this style of checklist should not be acceptable in
the 21st century. It has killed enough people already…
…The checklists as they stand are abysmally optimistic
and lethally time-consuming…


The McDonnell Douglas MD-11:
What kind of accident history does it have?

The MD-11, manufactured by the McDonnell Douglas Company, is
a derivative of the DC-10. Only 180 MD-11s were built…


The MD-11 Gestation

On the McDonnell Douglas MD-11, computers perform everything from
checklist tasks to stall recovery in an aircraft where the flight engineer’s
duties are accomplished by a bank of automatic controllers that run
the aircraft’s systems. The cockpit design distills the experience of
19 years and more than 16million hours of DC-10commercial airline
operation into computerized system controllers that operate hydraulic,
electrical, air (pneumatic) and fuelsystems…


Aging Aircraft In Our Skies

Is it a Practicable Solution (for Wiring Defects)?

…Many aircraft crews luck out by having their cockpit or cabin fires
in relatively benign environments (i.e.good weather, day-time with
a visual horizon to flyby, close to an emergency alternate airport,
electrical design-friendly airframe, etc). That means that 90% of
crews get away with it and don’t become a statistic. If there are no
statistics, just incidents, then FAA can get away with such statements
as: “To date we know of no passengers in the last ten years that have
died because of a wiring fault etc.” Statistics, when finely tuned, are
true deviltry in the hands of a bureaucrat… The Canadian TSB will
write the final report; it may be more honest than you would expect
from an FAA massaged NTSB report…


The History and Death of EVAS (Smoke Vision Devices):
An FAA Kill

…The 1970 tower-to-Swissair flight 330 transcript echo the words of
that Swissair flight 111 crew twenty-eight years later as each crew
tried to deal with dense continuous smoke in the cockpit…



…”The cardinal rule at Boeing is that you cannot bend a wire over
90 degrees, period.” Price said it’s also evident installers – the job
was subcontracted by Interactive Flight Technologies of Phoenix –
used pliers to bend the wires, another faux pas. He said it doesn’t
matter whether it was Kapton or Tefzel. “You don’t dare do that
with insulation material – you might damage it,” said Price.
“Any time you use pliers to make a bend on wire, that’s a no-no.
I saw a couple of examples of that in routing…”

The SWISSAIR Flight 111 Accident: Cockpit (CREW)
Resource Management in Airline Long-Haul Flights


MD-11 Insulation Fire Investigated


…Aircraft that disappear enroute beyond radar range
may never be located. If SR111’s fire had happened
90 minutes further on down track it would have simply vanished


Systemic Redundancy: Press Button A, or was it B?

…when the unthinkable happens and our aircraft’s Machiavellian
electronic system fails catastrophically, it is highly likely to
do so with toxic smoke and a distracting inferno – not just a
simple computer crash. What’s worse we cannot simply pull
the plug. We’ve got to ride it out…


Edward Block on Aircraft Wiring

…In 1977, TWA had asked Boeing not to put this insulation
(Kapton) in any more of their aircraft, and by 1984, the FAA’s
own internal documentation showed the problems being experienced
with this material. In 1987, the military finally banned Kapton
from further use, and in 1988 the FAA conducted their own
experiments on arc-tracking… however political issues have
remained in the equation to this day…

US Senate Hearings – Smoke in the Cockpit

…Would it surprise you to learn that since 1994 (this was
written in 1998) just in the FAA publicly available internet
data bases there are 783 reports of smoke in the cockpit, with
about half of the reports concerning commercial carriers?…

B737 Total Electric Power Loss on Approach
A Kaptonitis smoking gun?


Frayed wiring caused $1 billion explosion of spy satellite


WireFacts, 2008 August 07

FAA’s Reported Wire Incidents

…the wire incidents reported in the
FAA’s July 2008 Advisory Circular 43-16A…

WireFacts, 2006 June

Newsletter, June 2006: Wire Chafing on Aircraft

…In spite of the fact that wire chafing is a known problem
and the tools to resolve the issue are available, analysis
of data from years 2000-2004 wire failures modes on
U.S. Navy aircraft showed that chafing remained the leader
of all wire failure modes. Though the commercial aviation
industry experiences many of the same problems as the
armed services, much of the data from commercial aircraft
are not recorded and/or reported publicly…

WireFacts, 2005 November

Newsletter, Nov. 2005: Entanglement of Separation Standards

…In the final report of the Swissair Flight 111 crash
(caused by electrical arcing), the Transportation Safety
Board (TSB) of Canada found, “…that there are limitations…
In aircraft design, it is not always possible to maintain physical
separation between wires, especially in the cockpit area where,
typically, space available for installations is confined…”

WireFacts, 2004 August

Newsletter, Aug. 2004: Commandments of Wire Maintenance

…Splicing of wire should be kept to a minimum and
avoided entirely in locations subject to high vibration…
…circuit breaker failures are latent in nature, so
you won’t know they have failed until you need them…

WireFacts, 2004 February

Newsletter, Feb. 2004: The Life of a Wire

…Wire Maintenance Programs are as important for
new aircraft as they are for older, aging aircraft…

Journal of System Safety, 2006 May-June

A Short History of System Safety

…Safety must be designed and built into airplanes, just
as are performance, stability, and structural integrity.
A safety group must be just as important a part of a
manufacturer’s organization as a stress, aerodynamics,
or a weights group… Safety is a specialized subject
just as are aerodynamics and structures…

Wired, 1998 September 04

Swissair Update

Wired, 1998 September 04

Crash News ‘Unfiltered’

…Swissair is also flying relatives of victims to the crash
site from the United States and Europe at no cost, and
announced that it will pay families US$20,000 “to help
meet the immediate financial need that may be experienced.”
Upon arrival in Nova Scotia, relatives are invited to speak
with Red Cross counselors, clergy, and Swissair officials,
including the president of the airline, who arrived
in Halifax Friday…

Wired, 2000 June 30

Airlines Check Laptop Wiring

…More electronics are likely to be installed on aircraft in
coming years as airlines seek to offer inflight entertainment
and communications, including Internet access. But such
moves will be subject to rigorous safety procedures…
Any time a domestic aircraft is retrofitted with additional
wiring it must be recertified by the FAA…

Wired, 2001 May 11

Sky High E-Mail? Not So Fast

Fire Safety Engineering Group
School of Computing & Mathematical Sciences
University of Greenwich (no date)

Investigating the Swissair Flight 111 In-flight Fire
using the SMARTFIRE CFD fire simulation software

…Reconstruction of the wreckage disclosed that the fire pattern
was extensive and complex in nature. The fire damage created
significant challenges to identify the origin of the fire and to
appropriately explain the heat damage observed. The SMARTFIRE CFD
software was used to predict the possible behaviour of airflow
as well as the spread of fire and smoke within SR 111…

The Fifth Triennial International Fire & Cabin Safety Research Conference

Atlantic City, New Jersey 2007 October 29 – November 1

Cabin and Hidden Area Fire Protection

An Examination of the Effectiveness of Handheld Extinguishers
Against Hidden Fires in the Cabin Overhead Areas
of Standard and Widebody Transport Aircraft
Tim Marker, FAA Technical Center, Atlantic City Intl. Airport, NJ
Twenty handheld extinguisher tests were performed in the overhead
space of both narrow and wide body aircraft. The tests simulated a
typical hidden fire in the inaccessible area above the cabin ceiling…

Testing of Fire Ports to Discharge Handheld Extinguishers
into Inaccessible Areas on Aircraft, 2007 October 31

(pdf) Presentation (pdf 10M)

IAG’s Blog, 2005 July 26

Live TV on Singapore Airlines

…The airline is proceeding with plans to bring TV to seat-back
IFE (in-flight entertainment) by 2006. The four international
channels to be beamed live are BBC World, EuroNews,
Eurosportnews and CNBC….

IAG’s Blog, 2006 January 31

Inmarsat-based inflight email service

…Giving two-way access to corporate networks and public
Webmail services such as AOL, Hotmail and Yahoo, the service
is available via passengers’ own laptops supported by an in-seat
RJ-45 LAN (local area network) connector and a 110V AC power
supply. Users may view the headers of incoming emails before
electing to view them by committing to a price plan: $4.95 for
four hours or $9.95 for the duration of a longer flight…
Users can send and receive an unlimited number of emails of any
length, with attachments charged at a rate of ten cents per kilobyte…
The service uses Inmarsat‘s 3rd generation satellites…

New York Times, 2008 April 19

Airline Faults Shifting Rules About Safety

…something as simple as the direction of a bolt could be crucial.
“It may appear to be a minor detail, but in fact is considered to be
safety-related, because an airworthiness directive is based on a
known unsafe condition,” he said. Any change from the directive
must be analyzed and approved by the FAA, “no matter how
minor those details appear,” he added. The airworthiness
directive behind the groundings last week addressed how to
protect a cable from chafing against bolts on the airplane frame,
rubbing off the insulation and creating sparks. A backward bolt
could provide a rough edge that would cause damage, he said.
The order called for sheathing the cable bundle and securing it

Washington Post, 2008 May 17

American Accused of Shoddy Maintenance

…Maintenance work by American Airlines on hundreds of jets
was so sloppy that it posed a safety risk – a lapse that forced
the carrier to ground many of its planes and strand hundreds
of thousands of passengers last month, according to a report
by federal regulators released yesterday. “Left uncorrected,
the workmanship errors would have increased the odds that
[a plane] would have experienced arcing, smoke, or fire
problems that have caused serious incidents and fatal
accidents in the past,” the FAA said in the report…

Table of Contents

Transportation Safety Board

TSB Official Report on Swissair Flight 111

Published 27 March 2003

Table of Contents

1.0 Factual Information

1.14 Fire

1.6.10 Electrical System

1.9 Communications

1.11 Flight Recorders

2.0 Analysis

3.0 Conclusions

4.0 Safety Action

4.3.3 Aircraft Wiring Issues

5.0 Appendices

Appendix C Swissair ‘Smoke of Unknown Origin’ Checklist

NADA National Air Disaster Alliance

Swissair Flight 111 Archive

National Air Disaster Alliance, 2000 May

DOHSA – Death on the High Seas Act: Update

National Air Disaster Alliance Newslatter, 2000 May

DOHSA: Death on the High Seas Act

…Attorneys for Swissair 111 will argue the amended version
of DOHSA should apply because the accident occurred outside
the 12 mile limit, off the coast of the U.S., although the crash
occurred well within the limits of Canadian territorial waters…

National Air Disaster Alliance, (no date)

Mary Schiavo Speech

…Would it surprise you to learn that since 1994, just
in the FAA publicly available internet data bases there
are 783 reports of smoke in the cockpit, with about
half of the reports concerning commercial carriers?…

Air Safety Week, 2001 February 12

Fatal Flaws Should be Fixed, Families of Air Crash Victims Urge

Less time and more money is needed to fix known safety
deficiencies in airliners, according to one Tom O’Mara,
a member of the National Air Disaster Alliance (NADA)…
There are fixable fatal flaws on commercial jets that are
not fixed… The FAA should require all NTSB recommendations,
published as part of a final accident report, to be implemented
within 18 months. Sooner would be fine. We know the industry
feels this is a draconian measure. Not needed. Too expensive.
Too difficult, etc. We’ve heard it all. Think about it.
That’s all we ask…

National Air Disaster Alliance, 2001

Updated Goals 2001-2002

…In light of the…catastrophic wiring failure on Swissair 111,
wiring and cable need to be elevated to a Center of Excellence
status, with continual monitoring and surveillance, as well as
an action plan for replacement of defective wiring…

National Air Disaster Alliance Newslatter, 2001 March

Murielle Provost from Nova Scotia

…Within 2 hours of the crash of Swissair 111, Muriel
responded to the call and went directly to Peggy’s Cove.
She was appointed Coordinator for family services at
Peggy’s Cove, and was responsible for the welfare of
the emergency response personnel in her area…

National Air Disaster Alliance Newslatter, 2004 August 05

Newsletter, August 2004
…After the two highly-publicized airline crashes;
TWA Flight 800 in 1996 and Swissair 111 two years later,
the National Air Disaster Alliance convinced the FAA that
in considering new rules for air safety, passengers should
be represented on the various FAA committees that make
those recommendations. After all, airline operators,
airplane and airplane parts manufacturers, pilots, mechanics,
even NASA and the Department of Defense have a say,
why not those most affected, the people who lost loved
ones in air disasters?…

National Air Disaster Alliance, 2003 February

Doomed plane’s gaming system exposes holes in FAA oversight

Table of Contents