Swissair 111: Where Do We Go From Here?

Royal Aeronautical SocietyFlight Operations Group Meeting

London, EnglandOctober 22, 2008

Henry Wright, Board MemberTransportation Safety Board of Canada

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Presentation Outline

• About the TSB

• Recommendation process

• Swissair accident, TSB investigation and recommendations themes

• Call for action

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About the TSB

• Independent organization investigating marine, pipeline, rail and air occurrences

• Finds out what happened and why

• Makes recommendations to address safety deficiencies

• Not a regulator or a court

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TSB’s Methodology

• 1900 aviation occurrences reported each year

• Decision to investigate hinges on potential to reduce risks and/or increase safety

• SYSTEMATIC, THOROUGH, and UNBIASED investigations

• Important safety information made public immediately

• Recommendations for safety deficiencies involving significant risk and requiring immediate action

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Follow-up to Recommendations

• Regulator and industry take action to mitigate risks

• TSB tracks action taken and evaluates progress on recommendations

• Canadian Minister of Transport has 90 days to respond to a recommendation

• Assessment based on extent to which action completed or planned will mitigate risks

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Swissair Flight 111

Pilots smell an abnormal odour in the cockpit1011PM ADT

Pilots decided to divert to Halifax1015PM ADT

Pilots declare an emergency 1024PM ADT

Comm and Nav radios and other systems lost

1025 PM ADT

Halifax International

Airport

1031 PM ADT

Water impact

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Swissair Flight 111 (cont.)

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TSB’s Investigation – 1998 Swissair Accident

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Swissair 111 Recommendations

23 recommendations in regards to:

- on-board recorders

- circuit breaker resetting procedures

- supplemental type certification process

- material flammability

- in-flight firefighting

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8 Flammability Recommendations

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Flammability – Action Taken

• Directives mandated removal of MPET insulation

• New flammability test criteria established

• Guidance material developed for more accurate and consistent interpretation of test standards

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Flammability – Outstanding ActionMaterials

• Removal of MPET from all aircraft

• Comprehensive review of remaining types of insulation

• Quantification and mitigation of risks associated with all materials that failed the Radiant Panel Test

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Flammability – Outstanding ActionElectrical issues

– Establishment of test regime to evaluate aircraft electrical wire failure characteristics

– Evaluation of how aircraft systems and their components could exacerbate existing fire

In-flight entertainment network power supply unit cable segments

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Recorders

• Aviation leads the way with requirements for FDRs and CVRs

• The FAA published its final rule on FDR/CVR:– CVR two-hour recording capacity and independent power supply

providing 10 minutes of electrical power – power redundancy in that any single electrical failure must not result

in disabling both the CVR and the FDR (flight data recorder)

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Recorders – Outstanding Action

• Independent power supply for 2-hr CVRs

• Separate buses for CVRs and FDRs

• Protecting confidentiality of CVR or image recording systems for accident investigation purposes

• Harmonization with new FAA flight data recorder regulations

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In-Flight Firefighting

Area where fire originated – occurrence aircraft

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In-flight Firefighting – Action Taken

• Emergency procedures direct crews to prepare to land the aircraft without delay

• International Air Transport Association (IATA) workshop developed guidance material on smoke and fire cockpit checklist procedures

• Aircraft manufacturers improved their aircraft flight manuals

• Action plan established to improve current in-flight firefighting standards

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In-flight Firefighting – Outstanding Action

• Review of methodology for establishing designated fire zones

• Provision of improved fire-detection and fire suppression capabilities

• Continued adoption of emergency checklist by manufacturers and operators

• Assessment of inter-relationships between individual firefighting measures

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Conclusion

• We rely on collaboration with operators and regulators when conducting investigations

• While improvements have been made since Swissair, more action still required on 18/23 recommendations

• Change for the better can be made over and above regulatory requirements by operators and manufacturers

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In Memory Of

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Call for Action

• Mandatory international adoption of checklist templates

• Adoption of a more systematic approach to in-flight firefighting

• International harmonization of the protection afforded to cockpit voice and image recordings

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www.tsb.gc.ca

1998 - 2008

Swissair 111