The lasting legacy of the Swissair 111 investigation
30 August 2018
Posted by Vic Gerden
It has been 20 years since the Swissair 111 accident that triggered the largest multi-agency multi-national response and the most complex investigation in the history of the Transportation Safety Board of Canada (TSB).
On the evening of 2 September 1998, Swissair Flight 111 left New York for Geneva. Just over an hour later, the aircraft plunged into the dark waters of the Atlantic Ocean off Peggy’s Cove, Nova Scotia, with 229 people on board. The TSB investigation found that a fire aboard the plane started in a hidden area above the cockpit ceiling, when heat from the arcing of electrical wiring ignited thermal acoustic insulation material made of metallized polyethylene terephthalate (MPET) – a material that met the inadequate flammability certification standards in effect at the time of the accident.
As the TSB Investigator-in-Charge, I was impressed and very appreciative of the collaborative initial response. Support to the families and loved ones was very high on our list of priorities at the outset and remained so throughout the investigation. Many individuals and organizations shared that objective while assisting during the very challenging process of locating, recovering, transporting, and examining the millions of pieces of MD-11 aircraft.
Six different methods were ultimately used to recover 98% by weight of the aircraft. This permitted the investigation team to evaluate a huge amount of data and analyze a unique scenario – that of an onboard, localized fire that was suddenly quenched when the aircraft crashed into the water.
More than fifty organizations from all levels of government and industry sectors in Canada and abroad lent their support throughout the course of the investigation. Among those, the men and women of the Royal Canadian Mounted Police (RCMP) from across the Atlantic region provided superb assistance to families and vital assistance to the Chief Medical Examiner. They were also abundantly involved with wreckage recovery and examination, information collection and evaluation processes.
The Canadian Forces and the Navy in particular were instrumental in initially locating the main parts of the fuselage some 55 metres below the sea surface and guiding the preliminary work of about 200 divers, from both Canada and the USA. Among its many excellent contributions, the Canadian Coast Guard conducted sonar surveys of the wreckage site and transported salvaged parts to the shore.
Officials at Canadian Forces Base Shearwater put an aviation hangar at our disposal to examine the pieces of wreckage and reconstruct the front part of the fuselage – a necessary but laborious process that progressively confirmed the evidence of a sizable, localized fire near the front of the aircraft. Substantial additional testing and analysis was conducted at various locations in Canada, the USA and Switzerland.
To this day, I remain impressed by, and grateful to, the dedicated and conscientious individuals from the TSB and many other organizations that collaborated on the painstaking task of physically and digitally reconstructing the cockpit portion of the aircraft and analyzing the massive amount of information collected.
The investigation has had a lasting impact in advancing aviation safety around the world. Twenty of the 23 TSB recommendations have resulted in concrete safety actions. Perhaps the most significant change is that certain flammable materials such as MPET are no longer used in aircraft, reducing the risk of in-flight fires. More rigorous flammability testing along with enhanced regulations and standards were introduced to certify thermal insulation materials for use in aircraft. The industry in collaboration with the airline pilot associations developed international guidance on more effective smoke and fire checklist procedures. When smoke from an unknown source is detected, crews are trained to quickly start planning for immediate landing until they are assured there is no fire threat to the aircraft or occupants.
Numerous improvements have been made to international flight recorder standards to enhance the quantity, quality and integrity of information about the in-flight operation of aircraft. Mandatory cockpit voice recorders must now have a two-hour recording capacity; if two flight recorders are required, they must be powered by separate electrical sources. The industry has also taken steps to improve the quality of cockpit voice recordings.
Twenty years later, the results of the Swissair accident investigation continue to influence the increase in safety of aircraft materials, certification standards, ongoing aircraft modification and maintenance, and flight operations. I remain appreciative of the dedication and perseverance of the TSB investigators and all the amazing people from multiple national and international government organizations and commercial companies that cooperated fully to assist the TSB in making the 55 findings and 23 recommendations that have contributed significantly to aviation safety worldwide.
Vic Gerden was the TSB Investigator-in-Charge of the safety investigation of the Swissair 111 accident.
Mr. Gerden has an Engineering degree from Queen’s University, with extensive follow-up studies and experience in aerodynamics, avionics, propulsion systems, military and civilian flight operations, flight safety investigations, safety management, aerospace industry advocacy, business development, and management of collaborative R&D projects. He earned an Airline Transport Pilot (ATPL) license and has flown over 20 military and civilian aircraft and helicopter types.
His first career was with the Royal Canadian Air Force where he flew mainly fighter and trainer aircraft and worked in Germany, Belgium, England, USA, and most of the Canadian provinces. He achieved the rank of Colonel before changing careers and joining the TSB where his roles included Regional Manager, Central Region, Director Investigations (Air), and Senior Advisor, National & International Investigations.
After leaving the TSB in 2006, he has served as Executive Director and as Board Director of the Manitoba Aerospace Association. He was also the founding President and CEO of West Canitest R&D Inc (WestCaRD) which was initiated to support a GE-StandardAero collaboration at the Engine Testing Research & Development Centre and foster new technologies in Manitoba. He currently serves as a Director on the Board of WestCaRD, the Industrial Technology Centre, and chairs the Board of the Southport Aerospace Centre Corporation.
Mr. Gerden is currently the Principal at AeroPlus STM Services Inc, providing consulting services with focus on executive management support, including training, R&D project collaboration, business development, and aviation safety training.
Also on this subject
Aviation Investigation Report A98H0003
In-Flight Fire Leading to Collision with Water
Swissair Transport Limited
McDonnell Douglas MD-11 HB-IWF
Peggy’s Cove, Nova Scotia 5 nm SW
2 September 1998
Journey to the Bottom of the Sea; TSB Recorder blog by Peter Rowntree
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