AFTERMATH January 1999: Based on Canadian
probe, the U.S.'s National Transportation Safety Board
asks Federal Aviation Authority to inspect the cockpit
wiring of all MD-11s.
March 1999: Transportation Safety Board of Canada
urgently recommends flight recorders have independent
power sources and be able to record for two hours rather
than 30 minutes.
August 1999: FAA orders metallized Mylar blanket
insulation replaced, calling it fairly flammable.
Transportation Safety Board had issued urgent advisory
that Mylar use be reduced or eliminated.
September 1999: FAA bans the in-flight entertainment
system used on Flight 111, calling it "not compatible
with the design concept of the MD-11 airplane."
April 2000: Acting on a directive from Canadian
investigators, FAA orders map-reading lights on MD-11s
inspected or shut off. In inspections of about 12
aircraft, flammable Mylar blanket insulation was found
pressed against many of the lights and showed signs of
heat damage. Some lights were cracked.
April 2000: FAA issues eight safety orders concerning
MD-11 electrical systems, bringing to over 30 the number
of airworthiness directives released since the crash.
| | Smoke sensors needed Flight 111
fire started in area without detectors, safety board says
By Susan LeBlanc /
Staff Reporter
The fire aboard Swissair Flight 111 started in a compartment that
didn't even have a smoke detector, the Transportation Safety Board
of Canada said Monday.
That's just one of the industry safety failings the board
criticized in releasing a third set of recommendations stemming from
its investigation of the fatal Sept. 2, 1998, jet crash off Nova
Scotia.
"The industry has fallen short," said Benoit Bouchard, safety
board chairman.
When the pilots of the Geneva-bound MD-11 detected an odour and
then smoke soon after leaving New York, they thought it came from
the air conditioning unit and turned to standard troubleshooting
checklists.
But such checklists take too long to go through and should be
rewritten, said the safety board, adding Swissair has apparently
revamped its checklists.
Any smoke or odour should be considered an emergency that may
require landing immediately, the board recommended.
But the Swissair pilots obviously "had very little information to
go on," chief investigator Vic Gerden said at a news conference held
in an aircraft hangar at 12 Wing Shearwater.
Though flying over Queens County, the pilots considered heading
for Boston after detecting smoke. They also issued a "Pan, Pan, Pan"
warning, rather than the more serious "Mayday."
"There has tended to be some complacency in the aviation industry
concerning smoke or odour events," Mr. Gerden said.
The board called for adoption of smoke and odour detectors in
more areas of airplanes, plus better training and equipping of crews
to fight inflight fires. A Swissair representative could not be
reached, but a spokesman for Boeing said the recommendations
provided a comprehensive approach to dealing with the issue of
inflight fires.
"It's the best way to approach safety enhancements by looking
across the board, so we think that's an effective approach," Russ
Young said from Seattle.
Mr. Young said Boeing has already teamed up with Swissair to
develop fire detection equipment, which they began testing days ago.
The five recommendations were released against the backdrop of a
mockup of the plane's cockpit, reconstructed from some of the two
million pieces of jet recovered from the bottom of the Atlantic
Ocean.
Investigators also displayed mangled and charred sections of
fuselage, including pieces of the nose section's aluminum skin that
had been squished accordian-style.
All 229 crew and passengers aboard Flight 111 died.
More than two years later, investigators do not know the cause of
the fire but said it began in "the attic" above the dropped ceiling
in the cockpit area.
The attic is not considered a "fire zone," so has no smoke or
odour detection equipment, as the cargo compartment and lavatories
do.
The area is difficult to access.
"These areas have been considered by the industry as being
benign," Mr. Gerden said.
"It seems strange to us that in order to ensure public safety in
a time of so rapid technological advancement, we rely so much on the
human sense organs to detect (on-board) smoke or fire," Mr. Bouchard
said.
Though the probe has cost $50 million to $60 million and is the
most complex one ever undertaken worldwide, investigators may never
know what started the fire, Mr. Bouchard admitted.
Much attention has focused, however, on the plane's wiring.
Investigators have 21 wires that show signs of arcing, which is
similar to a short circuit.
As the investigation shifts officially to Ottawa on Dec. 15, wire
testing will continue. Investigators are also using custom 3-D
imaging computer software to learn more about the fire.
"Overall, today's recommendations emphasize the need for a
comprehensive, integrated approach to putting in place effective
inflight firefighting procedures," Mr. Gerden said.
But he stopped short of saying that the 229 people aboard the jet
would be alive today if such standards had been in place that night.
The recommendations emanating from the Swissair probe would cost
the airline industry about $1 billion to implement on existing
aircraft, Mr. Bouchard said, adding he hopes regulators and industry
react favourably to these latest findings.
Yet some of the recommendations, such as taking a tougher
attitude towards smoke and odour, would be easy to implement, Mr.
Gerden said.
Mr. Bouchard said he would like to see a report released on the
probe some time next year, but cannot guarantee it. A report has not
been issued on the crash of a TWA flight off Long Island in 1996,
Mr. Gerden said.
With The Canadian Press |