ALIFAX, Nova Scotia, March 27 — Canadian
investigators have concluded that the 1998 crash of Swissair
Flight 111, in which all 229 people on board were killed, was
caused by sparks from faulty wiring that ignited flammable
insulation above the cockpit, crippling the aircraft's
electrical system.
A report released today by the Transportation Board of
Canada stopped short of blaming any single factor for causing
the fire that doomed Flight 111 within an hour after the
plane, a McDonnell Douglas MD-11, took off for Switzerland
from New York's Kennedy International Airport.
But the report strongly suggested that a hastily installed
entertainment system that provided games for passengers in
first class and business class was probably at least partly to
blame for starting the fire, perhaps by overloading the
aircraft's inadequate electrical wiring.
The 338-page report is likely to spur international
airlines and regulators to improve wiring and maintenance and
inspection standards, remove flammable insulation that remains
in many aircraft and upgrade fire detection systems in
cockpits.
A haunting description of a disastrous but preventable
chain of events that began with a spark emerges from the
otherwise technical report.
Sparks from chipped or otherwise defective wiring ignited a
small creeping flame that gathered strength as it burned
through the thermal-acoustic insulation blankets above the
cockpit ceiling. No electronic warnings alerted the pilot and
crew of the blaze before it burned through flammable foam
material at the top of the cockpit's rear wall, causing the
fire to gather fatal momentum. The report found no fault with
the flight crew.
The aircraft crashed nose first at a steep angle into the
chilled waters off Nova Scotia just 20 minutes after the pilot
first smelled the fire.
"There was no requirement to have smoke or fire detectors
above the cockpit," Vic Gerden, the investigator in charge,
said at a news conference. "Such detectors could have provided
critical information to the crew."
Mr. Gerden emphasized that the accident would never have
happened if it had not been for the insulation blankets made
out of metalized polyethylene terephthalate, or MPET, which he
said were "readily ignitable" from sparks created by power
passing through bad wiring.
"It is important to emphasize here that without the
presence of this and other flammable material, this accident
would not have happened," he said.
Since the Swissair accident, the Federal Aviation
Administration ordered that the MPET insulation blankets be
removed from all aircraft registered in the United States.
But the Canadian investigators said the aviation industry
and regulators must go further to remove flammable materials
from aircraft, and their report recommends that international
regulators order the airline industry to install fire
detection systems in cockpits and stiffen testing for wiring.
The investigation was the most extensive ever in Canada for
an air disaster, taking four years and costing $40 million.
More than two million pieces of the shattered aircraft were
retrieved and 150 miles of electrical wire inspected.
Although the report determined exactly where the fire began
— on the right side of the cockpit, a short distance in front
of the rear wall — it did not conclusively pinpoint what
ignited the initial spark.
Wire damage believed to be part of the initial ignition was
found on one of the wires that supplied power to the in-flight
entertainment system, which included video and gambling games
and movies. But Mr. Gerden said that "it's important to
emphasize here that it is unlikely that this entertainment
system power supply wire was the only wire involved" in the
ignition.
"We strongly suspect," he said, "that at least one other
wire was involved, either an aircraft wire, or another
entertainment system wire."
Swissair, which is now bankrupt, removed the gaming system,
created by Interactive Flight Technologies, from all its
aircraft after the crash.
Many family members of the victims have said they believe
that the entertainment system was at fault for the crash, and
that American regulators should never have approved the
system.
"There is a lack of individual and corporate
responsibility," said Mark Fetherolf, of Palm Beach, Fla.,
whose daughter was on Flight 111. "There also remains deep
concern whether the recommendations of the report are adopted
enthusiastically by the industry and regulatory bodies."