A spark from a wire surrounded by flammable insulation blankets hidden
in the ceiling of Swissair Flight 111 started the fatal fire that sent the
plane hurtling into the ocean, killing all 229 people aboard near Peggy?s
Cove more than four years ago.
In a comprehensive 337-page report released yesterday at the World
Trade and Convention Centre, the Transportation Safety Board found that
wires supplying power to the MD-11 aircraft?s controversial inflight
entertainment unit showed damage consistent with wire arcing, a type of
short circuit generating very high temperatures when its insulation is
broken or rubbed off.
But tests showed that silver foil insulation blankets packed around the
wires in the cockpit ceiling above the co-pilot?s seat were readily
ignited and likely spread the fire through the ceiling before pilots could
take action.
?It is important to emphasize here that without the presence of this
and other flammable material, this accident would not have happened,? said
lead investigator Vic Gerden.
The high-tech entertainment system has long been suspected as the cause
of the fire because of the way it was installed and certified.
The board said the certification of non-essential electronic equipment
remains a concern.
The entertainment system is no longer in use and the flammable
insulation blankets are slowly being removed from about 700 large-bodied
jets worldwide still equipped with the insulation.
Gerden said it?s unlikely the entertainment system power supply was the
only arced wire, but it?s impossible to pinpoint what other wires arced in
the fire-damaged area of the plane.
Board investigators believe that by the time the pilots realized the
urgency of their situation, the fire had already spread and that
conditions inside the cockpit of the plane were rapidly deteriorating.
?Because of the rapid progression of the fire, they would not have been
able to complete a safe landing in Halifax,? said Gerden.
Gerden said the fire aboard Swissair Flight 111 was a ?wake-up call?
for the aviation industry.
The board has recommended tougher flammability standards and stringent
tests for material used in aircraft, some of which are now in use. ?With
today?s report, we?ve asked the bar be raised a bit more,? he said.
The board made 23 safety recommendations, including nine new ones
yesterday. It?s the culmination of nearly 41/2 years of work by
investigators at the cost of $57 million dollars.
Flight 111 crashed on Sept. 2, 1998 at the mouth of St.Margaret?s Bay,
about 10 kilometres southwest of Peggy?s Cove.
Board chairman Camille Theriault called the investigation one of the
most complex yet by any safety agency.
It was made easier by the co-operation of hundreds of people, in
particular the residents of communities around St. Margarets Bay, many who
personally helped the families of victims.?Thank you for showing the world
the very best of our national character,? he said.
rdooley@hfxnews.ca
Swissair Flight 111 Sept. 2, 1998
The jumbo jet went down off the coast of Nova Scotia, near Peggy?s
Cove.
Highlights from the Transportation Safety Board?s final report on the
1998 crash:
- The fire that led to the crash most likely started from electrical
arcing that began in wiring above the ceiling on the right side of the
cockpit.
- Investigators found evidence of electrical arcing in a cable
associated with the plane?s inflight entertainment system, but were
unable to pinpoint it as the definitive cause of the crash.
- The arcing ignited flammable cover material on nearby thermal
acoustic insulation blankets and quickly spread. The board concluded
that certification standards for material flammability were inadequate.
- The board cleared the pilots of any wrongdoing. Investigators
determined the pilots wouldn?t have been able to land the plane safely
even if they had tried to do so immediately after declaring an
emergency.
- The board made 23 recommendations, nine of them new. Four of them
propose improvements to ?the capture and storage of flight data? on
cockpit voice recorders, flight-data recorders, and cockpit image
recording systems.
Results of the Swissair crash and investigation:
- New provincial Emergency Measures Organization operations centre in
Dartmouth opens after an extensive review of the organization?s response
to the crash. Military, coast guard and government agency co-operation
in times of crisis is re-examined and improved after extensive
debriefing of officials involved with the response to the crash of
Swissair Flight 111.
- Three memorial sites are designated by the province. One is near
Peggy?s Cove, the other is a burial site in Bayswater and the third is
the actual crash site near Pearl Island at the mouth of St. Margaret?s
Bay.
- Cultural and educational exchange to France and Switzerland for Nova
Scotia students in 2000 as a gift from European families of victims of
the disaster.
- The Maritime Muslim Academy is established with a gift from the
family of a Saudi Arabian prince killed in the Swissair crash.
- The crash investigation focused international attention on several
key aspects of aviation safety. The length of time flight-data and
cockpit-voice recorders store information; the flammability of material
used to insulate airplanes; and the procedures pilots follow when smoke
is detected in-flight.
- Investigative techniques also changed dramatically with the probe.
For the first time detailed computer models were used to map the spread
of the cockpit fire that disabled the aircraft. The technique vastly
improved the ability of investigators to reconstruct scenarios that
contributed to the fire and the subsequent crash.
- In the U.S., the crash became the focal point for several groups
lobbying the Federal Aviation Administration for improvements to air
safety. The International Air Safety Association, founded by Lyn Romano,
became the lead organization lobbying for better aviation safety.
Romano?s husband Ray was killed in the Swissair crash.