US embassy cable - 03HALIFAX93

UNCLAS HALIFAX 0093 
 
SIPDIS 
 
DEPT FOR CA/OCS, WHA/CAN, AND EB/TRAN 
USDOT PLEASE PASS NTSB 
 
E.O. 12958: N/A 
TAGS: CASC, EAIR, CA, US, Transportation 
SUBJECT:  CANADIAN TRANSPORTATION SAFETY BOARD 
RELEASES FINAL REPORT ON CRASH OF SWISSAIR FLIGHT 111 
 
 
1. THE TRANSPORTATION SAFETY BOARD OF CANADA (TSB) TODAY RELEASED 
ITS FINAL REPORT ON SWISSAIR FLIGHT 111, WHICH CRASHED OFF THE 
COAST OF NOVA SCOTIA ON SEPTEMBER 2, 1998, KILLING ALL ABOARD, 
INCLUDING 103 AMERICAN CITIZENS.  THIS REPORT MARKS THE 
CONCLUSION OF THE TSB'S LONGEST AND MOST EXTENSIVE CRASH 
INVESTIGATION EVER, CONDUCTED AT A TOTAL COST OF C$ 57 MILLION. 
 
2. THE TSB CONCLUDED THAT THE ONBOARD FIRE WHICH LED TO THE CRASH 
OF SWISSAIR 111 STARTED IN A HIDDEN OVERHEAD AREA ON THE 
STARBOARD SIDE OF THE PLANE JUST ABOVE AND AT THE REAR OF THE 
COCKPIT AREA.  THE SOURCE OF IGNITION WAS AN ARCING EVENT IN THE 
AIRCRAFT'S ELECTRICAL WIRING.   THE TSB PINPOINTED ONE PARTICULAR 
SECTION OF WIRING FROM THE AIRCRAFT'S IN-FLIGHT ENTERTAINMENT 
SYSTEM FOR BUSINESS CLASS PASSENGERS AS BEING ASSOCIATED WITH THE 
INITIAL ARCING EVENT, THOUGH THEY COULD NOT SAY WITH CERTAINTY 
THAT THE ARCING THAT OCCURRED THERE WAS IN FACT THE LEAD EVENT. 
THE TSB CONCLUDED THAT ARCING ALSO OCCURRED AT OTHER POINTS IN 
THE WIRING FOR THE IN FLIGHT ENTERTAINMENT SYSTEM WHICH WERE NOT 
RECOVERED, MAKING IT IMPOSSIBLE TO ISOLATE THE LEAD ARCING EVENT. 
THIS ARCING IGNITED THE METALLIZED POLYETHELENE TEREPHTHALATE 
(MPET) MATERIAL ON THE INSULATION BLANKETS ABOVE THE CEILING OF 
THE RIGHT REAR COCKPIT AREA.  THE TSB CONCLUDED THAT THE MPET 
BLANKETS WERE EXCESSIVELY FLAMMABLE AND THAT ABSENT THE PRESENCE 
OF FLAMMABLE MATERIAL IN THE VICINITY OF THE INITIAL ARCING 
EVENT, THE DISASTER WOULD NOT HAVE OCCURRED. 
 
3. THE TSB NOTED THAT FIRE/SMOKE DETECTION AND SUPPRESSION 
DEVISES WERE NOT PRESENT IN THE AREA WHERE THE FIRE STARTED, AND 
WERE NOT REQUIRED AT THAT TIME.  THE TSB CONCLUDED THAT THE 
FLIGHT CREW DID NOT HAVE THE NECESSARY TOOLS, PROCEDURES, OR 
TRAINING TO LOCATE AND ELIMINATE THE FIRE BEFORE IT BECAME 
UNCONTROLLABLE.  THE TSB ALSO CONCLUDED THAT AIR CIRCULATION 
CHARACTERISTICS ABOARD THE AIRCRAFT VENTED SMOKE AWAY FROM THE 
CREW INITIALLY.  THIS CONTRIBUTED TO A DELAY IN RECOGNIZING THE 
EXTREMELY SERIOUS NATURE OF THE SITUATION, AND LED THEM INITIALLY 
TO ERRONEOUSLY BELIEVE THAT THE SMELL THEY DETECTED WAS THE 
RESULT OF AN ANOMALY IN THE AIR CONDITIONING SYSTEM INSTEAD OF AN 
ONBOARD FIRE. 
 
4. HOWEVER, THE TSB ALSO CONCLUDED THAT AN ACCURATE EARLY 
ASSESSMENT OF THE SITUATION WOULD STILL NOT HAVE GIVEN THE CREW 
OF SWISSAIR 111 SUFFICIENT TIME TO EXECUTE A SAFE EMERGENCY 
LANDING IN HALIFAX.  THE TSB CONCLUDED THAT, GIVEN IDEAL 
CONDITIONS, THE EARLIEST MOMENT THAT SWISSAIR 111 COULD HAVE 
LANDED WAS 22:27 LOCAL TIME.  HOWEVER, THE ONBOARD FIRE RESULTED 
IN A RAPID DETERIORATION OF FLIGHT CONTROL SYSTEMS IN THE COCKPIT 
AT 22:25.  THE TSB THEREFORE CONCLUDED THAT THE CREW WOULD HAVE 
LOST CONTROL OF THE AIRCRAFT SHORT OF THE RUNWAY EVEN IF THEY HAD 
ACTED IMMEDIATELY TO EXECUTE AN EMERGENCY LANDING AT THE MOMENT 
THEY FIRST SMELLED SMOKE. 
 
5. IN ADDITION TO THE 14 AVIATION SAFETY RECOMMENDATIONS ALREADY 
MADE IN THE COURSE OF THIS INVESTIGATION, THE TSB RELEASED AN 
ADDITIONAL NINE RECOMMENDATIONS IN CONJUNCTION WITH THEIR FINAL 
REPORT.  THESE RECOMMENDATIONS DEAL WITH TESTING AND FLAMMABILITY 
STANDARDS FOR INSULATION MATERIALS, WITH AIRCRAFT ELECTRICAL 
SYSTEMS INCLUDING CERTIFICATION OF ADD-ON ELECTRICAL SYSTEMS FOR 
COMMERCIAL AIRCRAFT, AND IMPROVEMENTS TO THE CAPTURE AND STORAGE 
OF IN FLIGHT DATA. 
 
6. THE TSB OFFICIALS PRESENT EMPHASIZED THAT THE PURPOSE OF THEIR 
INVESTIGATION IS TO IMPROVE AVIATION SAFETY AND TO PREVENT FUTURE 
TRAGEDIES, NOT TO ASSIGN BLAME OR LIABILITY FOR THE CRASH OF 
SWISSAIR 111.  THEY EXPRESSED CONFIDENCE THAT THE RECOMMENDATIONS 
PRODUCED AS A RESULT OF THEIR INVESTIGATION HAVE AND WILL 
CONTINUE TO IMPROVE AVIATION SAFETY.  WHETHER THE INFORMATION IN 
THEIR FINAL REPORT WILL PROVIDE ANY MEASURE OF CLOSURE OR 
SATISFACTION FOR THE FAMILIES OF THE VICTIMS OF SWISSAIR REMAINS 
TO BE SEEN.  THE TSB REPORT IS AVAILABLE IN FULL AT: 
HTTP//WWW.TSB.GC.CA. 
 
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