ALIFAX, Nova Scotia -- A fire probably caused by an electrical
spark crept undetected along the insulation of Swissair Flight 111 four
years ago, giving the pilots no chance to save the 229 people on board,
investigators concluded yesterday.
Canada's Transportation Safety Board ended its largest investigation
ever -- lasting more than four years and costing more than $30 million --
without being able to declare unequivocally what caused the fire that
brought down the MD-11 airliner off the coast of Nova Scotia on Sept. 2,
1998.
The 338-page report focused on the in-flight entertainment system
aboard the McDonnell-Douglas aircraft, saying a problem with the wiring to
power the system went undetected and the spark ''most likely'' started
there.
It said the US Federal Aviation Administration's certifying system
failed to ensure that the entertainment system was designed and installed
properly for the MD-11. However, chief investigator Vic Gerden said a
wiring flaw detected by investigators in the entertainment system did not
spark the fire.
The report included nine safety recommendations involving testing for
insulation materials and electrical systems, and improving the flight
cockpit and data recording systems.
Safety board investigators previously made 14 recommendations that led
to the removal of flammable insulation material from aircraft and improved
fire reaction measures for pilots.
''This has been the largest, most complex aviation investigation the
TSB has ever undertaken,'' safety board chairman Camille Theriault said.
''The efforts of thousands of hardworking people from various countries,
industries and regulatory authorities have culminated in a comprehensive
report that has changed the face of aviation safety.''
Relatives of passengers killed in the crash said the FAA and other
regulators should implement the recommendations immediately.
''There are problems, serious problems, with the wiring of aircraft,''
said Miles Gerety of Redding, Conn., whose brother, Pierce, was killed.
''I wonder if the FAA will make the airlines spend the money.''
Swissair Flight 111 plunged into the Atlantic Ocean off the Nova Scotia
coast while en route from New York to Geneva. Pilots reported smoke in the
cockpit 53 minutes into the trip, and the electrical systems began failing
13 minutes later.
Since the crash, Swissair has gone out of business in the wake of the
Sept. 11, 2001, terrorist attacks in the United States that crippled the
airline industry.
The report provided a clinical and sobering account of the tragedy,
telling how a spark in the wiring of the in-flight entertainment system
probably started a fire that slowly burned its way through insulation
above the cockpit.
''It was determined that the fire most likely started from an
electrical arcing event that occurred above the ceiling on the right side
of the cockpit,'' the executive summary said.
It offered no specific reason for what caused the spark, but the
recommendations include measures to certify additional systems such as the
in-flight entertainment systems and raise industry standards for resetting
circuit breakers.
Gerry Einarsson, a former Canadian government transport engineer,
recently said the entertainment system, which allows passengers to view
videos and play computer games, required excessive amounts of operating
power that resulted in higher cabin temperatures.
The report noted that a check of 15 other Swissair MD-11s showed the
wiring for the entertainment system was installed differently on four of
them.
''The overall result,'' it said, was that the FAA's certification of
the entertainment system ''did not ensure that all the required elements
were in place to design, install, and certify a system that would be
compatible with the MD-11 type certificate.''
A lack of smoke or fire detection and suppression devices, which were
not required at the time, left the crew with few resources, the report
said. The pilots had no chance to try an emergency landing.
''We have concluded that, even if the pilots could have foreseen the
eventual deterioration due to the fire -- because of the rapid progression
of the fire, they would not have been able to complete a safe landing,''
Gerden said.
