Swissair Flight 111
HB-IWF, the aircraft involved in the accident, seen at Zurich Airport in July 1998.
|Date||2 September 1998|
|Summary||In-flight fire leading to electrical failure, spatial disorientation and crew distraction|
|Site||Atlantic Ocean, near St. Margarets Bay, Nova Scotia, Canada|
|Aircraft type||McDonnell Douglas MD-11|
|Flight origin||John F. Kennedy Int'l Airport
New York City, United States
|Destination||Cointrin International Airport
Swissair Flight 111 (SR111, SWR111) was a Swissair McDonnell Douglas MD-11 on a scheduled airline flight from John F. Kennedy International Airport in New York City, United States to Cointrin International Airport in Geneva, Switzerland. This flight was also a codeshare flight with Delta Air Lines.
On Wednesday, 2 September 1998, the aircraft used for the flight, registered HB-IWF, crashed into the Atlantic Ocean southwest of Halifax International Airport at the entrance to St. Margarets Bay, Nova Scotia. The crash site was 8 kilometres (5.0 mi) from shore, roughly equidistant from the tiny fishing and tourist communities of Peggys Cove and Bayswater. All 229 people on board died—the highest death toll of any aviation accident involving a McDonnell Douglas MD-11 and the second-highest of any air disaster in the history of Canada, after Arrow Air Flight 1285.
The initial search and rescue response, crash recovery operation, and resulting investigation by the Government of Canada took over four years and cost CAD 57 million (at that time approximately USD 38 million). The Transportation Safety Board of Canada's (TSB) official report of their investigation stated that flammable material used in the aircraft's structure allowed a fire to spread beyond the control of the crew, resulting in a loss of control and the crash of the aircraft.
- 1 History
- 2 Victims
- 3 Examination and investigation
- 4 Legacy
- 5 See also
- 6 References
- 7 Further reading
- 8 External links
The aircraft, a McDonnell Douglas MD-11, serial number 48448 registered HB-IWF, was manufactured in 1991 and Swissair was its only operator. It bore the title of Vaud, in honor of the Swiss canton of the same name. The airframe had a total of 36,041 hours. The three engines were Pratt & Whitney 4462s. The cabin was configured with 241 seats (12 six-abreast first-, 49 seven-abreast business-, and 180 nine-abreast economy-class). First- and business-class seats were equipped with an in seat in-flight entertainment system, installed at some point after initial entry into service.
An MD-11 has a standard flight crew consisting of a captain and a first officer, as well as a cabin crew made up of a maître de cabine (M/C - purser) supervising the work of 11 flight attendants. All personnel on board Swissair Flight 111 were qualified, certified, and trained in accordance with Swiss regulations under the Joint Aviation Authorities (JAA). The cockpit crew consisted of 50-year-old Captain Urs Zimmermann and 36-year-old First Officer Stefan Löw,  both experienced pilots with 10,800 flight hours and 4,800 flight hours, respectively. The captain was also an instructor pilot for the MD-11. 
Flight and crash
The flight took off from New York's John F. Kennedy Airport at 20:18 Eastern Daylight Time (00:18 UTC). From 20:33 EDT (00:33 UTC) until 20:47 EDT (00:47 UTC), the aircraft experienced an unexplained thirteen-minute radio blackout. The cause of the blackout was determined to be an error in the tuning of the communication radios.
At 22:10 Atlantic Time (01:10 UTC), cruising at FL330 (approximately 33,000 feet or 10,100 metres), the flight crew — Captain Urs Zimmermann and First Officer Stephan Löw — detected an odor in the cockpit and determined it to be smoke from the air conditioning system, a situation easily remedied by closing the air conditioning vent, which a flight attendant did on Zimmermann's request. Four minutes later, the odor returned and now smoke was visible; the pilots began to consider diverting to a nearby airport for the purpose of a quick landing. At 22:14 AT (01:14 UTC), the flight crew made a "Pan-pan" radio call to ATC Moncton (which handles trans-Atlantic air traffic approaching or departing North American air space), indicating that there was an urgent problem with the flight, but not an emergency (denoted by a "Mayday" call) which would imply immediate danger to the aircraft, and requested a diversion to Boston's Logan International Airport, which at that time was 300 nautical miles (560 km) away. ATC Moncton offered the crew a vector to the closer Halifax International Airport in Enfield, Nova Scotia, 66 nm (104 km) away, which Löw accepted. The crew then put on their oxygen masks and began their descent. Zimmermann put Löw in charge of the descent while he personally ran through the two Swissair standard checklists for smoke in the cockpit, a process that would take approximately 20 minutes and become a later source of controversy.
At 22:18 AT (01:18 UTC), ATC Moncton handed over traffic control of the plane to ATC Halifax, since the plane was now going to land in Halifax rather than leave North American air space. At 22:19 AT (01:19 UTC), the plane was 30 nautical miles (56 km) away from Halifax International Airport, but Löw requested more time for the aircraft to descend from 21,000 feet (6,400 m). At 22:20 AT (01:20 UTC), Löw informed ATC Halifax that he needed to dump fuel. ATC Halifax subsequently diverted the plane toward St. Margaret's Bay, where it could more safely dump fuel but still be only around 30 nautical miles (56 km) from Halifax.
In accordance with the Swissair checklist entitled "In case of smoke of unknown origin", the crew shut off the power supply in the cabin, which caused the recirculating fans in the ceiling to shut off. This caused a vacuum in the ceiling space above the passenger cabin which induced the fire to spread into the cockpit, causing the autopilot to shut down; at 22:24:28 AT (01:24:28 UTC), Löw informed ATC Halifax that "we now must fly manually." Seventeen seconds later, at 22:24:45 AT (01:24:45 UTC), Löw informed ATC Halifax that "Swissair 111 heavy is declaring emergency" repeated the emergency declaration one second later, and over the next 10 seconds stated that they had descended to "between 12,000 and 5,000 feet" and once more declared an emergency. The flight data recorder stopped recording at 22:25:40 AT (01:25:40 UTC), followed one second later by the cockpit voice recorder. The plane briefly appeared again on radar screens from 22:25:50 AT (01:25:50 UTC) until 22:26:04 AT (01:26:04 UTC). Its last recorded altitude was 9,700 feet. Shortly after the first emergency declaration, the captain could be heard leaving his seat to fight the fire, which was now spreading to the rear of the cockpit; the Swissair volume of checklists was later found fused together in the wreckage, indicating that the captain may have attempted to use them to fan back the flames. The captain did not return to his seat; whether he was killed from the fire, asphyxiated by the smoke, or killed in the crash is not known. Physical evidence provides an indication that First Officer Löw may have survived the inferno only to die in the eventual crash; instruments show that Löw continued trying to fly the now-crippled aircraft and gauges later indicated that he shut down engine two due to an engine fire warning approximately one minute before impact, implying he was still alive and at the controls until the final moments of the flight. The aircraft struck the ocean at 22:31 AT (01:31 UTC) at an estimated speed of 345 mph (555 km/h, 154 m/s, or 299 knots) and with a force of 350g, causing the aircraft to disintegrate into millions of pieces. The crash location was approximately Coordinates: , with 300 meters' uncertainty.
Search and rescue operation
The search and rescue operation was code-named Operation Persistence and was launched immediately by Joint Rescue Coordination Centre Halifax (JRCC Halifax), which tasked the Canadian Forces Air Command, Maritime Command, and Land Force Command, as well as the Canadian Coast Guard (CCG) and Canadian Coast Guard Auxiliary (CCGA) resources.
The first rescue resources to approach the crash site were Canadian Coast Guard Auxiliary volunteer units - mostly privately owned fishing boats - sailing from Peggy's Cove, Bayswater, and other harbors on St. Margaret's Bay and the Aspotogan Peninsula. They were soon joined by the dedicated Canadian Coast Guard SAR vessel CCGS Sambro and CH-113 Labrador SAR helicopters flown by the 413 Squadron from CFB Greenwood.
The crash site's proximity to Halifax meant that ships docked at Canada's largest naval base, CFB Halifax, as well as one of the largest Canadian Coast Guard bases, CCG Base Dartmouth, were within one hour's sailing time. Calls immediately went out and ships sailed as soon as possible for St. Margaret's Bay.
The U.S. Navy also assisted in the recovery efforts.
- Canadian Coast Guard ships
- Canadian Forces warships
HMCS Kingston (MM 700), HMCS Preserver (AOR 510), HMCS Ville de Québec (FFH 332), HMCS Halifax (FFH 330), HMCS Glace Bay (MM 701), HMCS Goose Bay (MM 707), HMCS Moncton (MM 708), HMCS Anticosti (MSA 110)
- Canadian Forces submarines
- Canadian Forces auxiliary vessels
The HMCS Preserver was assigned as the on-scene commander of Operation Persistence and had authority over all aircraft and vessels within the area surrounding the crash site.
Search and recovery operation
By the afternoon of 3 September, it was apparent that there were no survivors from the crash and JRCC Halifax de-tasked dedicated SAR assets (CCGS Sambro and the CH-113 Labrador helicopters). The Royal Canadian Mounted Police were given overall command of the recovery operation, with HMCS Preserver (AOR 510) remaining on-scene commander.
The aircraft broke up on impact with the water and most of the debris sank to the ocean floor (a depth of 55 m or 180 ft). Some debris was found floating in the crash area and over the following weeks debris washed up on the nearby shorelines.
The initial focus of the recovery was on finding and identifying human remains and on recovering the flight recorders, but this proved difficult, as the force of impact was "in the order of at least 350 g" and the environmental conditions only allowed the recovery of human remains along with the aircraft wreckage. Only one of the victims was visually identifiable. Eventually, 147 were identified by fingerprint, dental records, and X-ray comparisons. The remaining 81 were identified through DNA tests.
A request was made by the Government of Canada to the Government of the United States for a dedicated salvage ship. The USS Grapple (ARS-53) was tasked to the recovery effort, arriving from Philadelphia on September 9. Among Grapple's crew were 32 salvage divers.
The cockpit voice recorder (CVR) and flight data recorder (FDR) were found by the submarine HMCS Okanagan (S74) using sonar to detect the underwater locator beacon signals and were quickly retrieved by Navy divers (the FDR on 6 September and the CVR on 11 September 1998). Both had stopped recording when the aircraft lost electrical power at approximately 10,000 ft (3,000 m), 5 minutes and 37 seconds before impact.
The recovery operation was guided by the Transportation Safety Board of Canada (TSB) with resources from the Canadian Forces, Canadian Coast Guard, RCMP, and other agencies. The area was surveyed using route survey sonar, laser line scanners, and remotely operated vehicles to locate items. After being located, the debris was then recovered (initially by divers and ROV's, later by dredging and trawling).
On 2 October 1998, the TSB initiated a heavy lift operation to retrieve the major portion of the wreckage from the deep water before the expected winter storms began. By 21 October, an estimated 27% of the wreckage was recovered.
At that point in the investigation, the crash was generally believed to have been caused by faulty wiring in the cockpit after the entertainment system in the plane started to overheat. Certain groups issued Aviation Safety Recommendations. The TSB released its preliminary report on 30 August 2000 and the final report in 2003.
The final phase of wreckage recovery employed the ship Queen of the Netherlands to dredge the remaining aircraft debris. It concluded in December 1999 with 98% of the aircraft retrieved: approximately 126,554 kg (279,000 lb) of aircraft debris and 18,144 kg (40,000 lb) of cargo.
Response to victims' families and friends
The airport used the JFK Ramada Plaza to house relatives and friends of the victims of the crash, due to the hotel's central location relative to the airport. Due to its role in housing friends and relatives of several aircraft crashes, the hotel became known as the "Heartbreak Hotel". Jerome "Jerry" Hauer, the head of the emergency management task force of Mayor of New York City Rudy Giuliani, praised the response of Swissair and codeshare partner Delta Air Lines in responding to the accident: he had criticized Trans World Airlines in its response to the TWA Flight 800 crash in 1996.
|Final tally of passenger nationalities|
|Canada and Morocco||1||0||1|
|People's Republic of China||1||0||1|
|France and United Kingdom||1||0||1|
|France and United States||2||0||2|
|Greece and United States||1||0||1|
|Iran and United States||1||0||1|
|Israel and Switzerland||1||0||1|
|Saint Kitts and Nevis||2||0||2|
|Switzerland and Netherlands||1||0||1|
|Switzerland and United Kingdom||2||0||2|
|Switzerland and United States||1||0||1|
|United Kingdom and United States||2||0||2|
One hundred thirty-two Americans (including one Delta Air Lines flight attendant and two infants), 41 Swiss (including 13 crew members), 30 French, six Britons, three Germans, three Italians, three Canadians, two Greeks, two Lebanese, one each from Afghanistan, China, India, Iran, Russia, Saudi Arabia, Spain, St. Kitts and Nevis, Sweden, and Yugoslavia, and four others were on board.
Several notable individuals died in this accident, including:
- Pierce J. Gerety, Jr., UNHCR Director of Operations for the Great Lakes Region of Africa, who was on a special mission for U.N. Secretary General Kofi Annan to the Democratic Republic of the Congo to attempt to negotiate a peace accord with Laurent Kabila in an erupting regional war
- Joseph LaMotta, son of former boxing world champion Jake LaMotta
- Jonathan Mann, former head of the WHO's AIDS program, and his wife, AIDS researcher Mary Lou Clements-Mann
- European Synchrotron Radiation Facility (ESRF) physicist Per Spanne, who had been working at Brookhaven National Laboratory since 1996
- Prof. Victor Rizza, professor of Pharmacology, University of Catania, Italy.
The Royal Canadian Mounted Police (RCMP) medical examiners identified most of the bodies within 10 weeks of the accident. Only one body was identifiable by sight. For approximately 100 bodies, the examiners used DNA; the DNA analysis has been referred to as the largest DNA identification project in Canadian history. About 90 bodies were identified by Canadian medical examiners using dental records. For around 30 bodies, examiners used fingerprints and ante mortem (before death) X-rays. The large number of ante mortem dental X-rays meant that around 90 bodies had been identified by the end of October. The RCMP contacted relatives of victims to ask for medical histories and dental records. Blood samples from relatives were used in the DNA identification of victims.
Examination and investigation
An estimated 2 million pieces of debris were recovered and brought ashore for inspection at a secure handling facility in a marine industrial park at Sheet Harbour, where small material was hand inspected by teams of RCMP officers looking for human remains, personal effects, and valuables from the aircraft's cargo hold. The material was then transported to CFB Shearwater, where it was assembled and inspected by over 350 investigators from multiple organizations, such as the TSB, NTSB, FAA, AAIB, Boeing, Pratt & Whitney, and Swissair.
As each piece of wreckage was brought in, it was carefully cleaned with fresh water, sorted, and weighed. The item was then placed in a specific area of a hangar at CFB Shearwater, based on a grid system representing the various sections of the plane. All items not considered significant to the crash were stored with similar items in large boxes. When a box was full, it was weighed and moved to a custom-built temporary structure (J-Hangar) on a discontinued runway for long-term storage. If deemed significant to the investigation, the item was documented, photographed, and kept in the active examination hangar. Particular attention was paid to any item showing heat damage, burns, or other unusual marks.
The lack of flight recorder data for the last six minutes of the flight added significant complexity to the investigation and was a major factor in its lengthy duration. The Transportation Safety Board team had to reconstruct the last six minutes of flight entirely from the physical evidence. As the aircraft was broken into 2 million pieces by the impact, this process was time-consuming and tedious. The investigation became the largest and most expensive transport accident investigation in Canadian history, costing C$57 million (US$48.5 million) over five years.
Cockpit and recordings
The front 10 m (33 ft) of the aircraft, from the front of the cockpit to near the front of the first-class passenger cabin, was reconstructed. Information gained by this allowed investigators to determine the severity and limits of the fire damage, its possible origins, and progression. The cockpit voice recorder used a 1/4 inch recording tape that operated on a 30 minute loop. It therefore only retained the half hour of the flight before the recorders failed, six minutes before the crash. The CVR recording and transcript are protected by a strict privilege under section 28 of the Canadian Transportation Accident Investigation and Safety Board Act and thus have not been publicly disclosed. The air traffic control recordings are less strictly privileged: section 29 of the same act provides only that they may not be used in certain legal proceedings. The air traffic control transcripts were released within days of the crash in 1998 and the air traffic control audio was released in May 2007.
The investigation identified eleven causes and contributing factors of the crash in its final report. The first and most important was:
Aircraft certification standards for material flammability were inadequate in that they allowed the use of materials that could be ignited and sustain or propagate fire. Consequently, flammable material propagated a fire that started above the ceiling on the right side of the cockpit near the cockpit rear wall. The fire spread and intensified rapidly to the extent that it degraded aircraft systems and the cockpit environment, and ultimately led to the loss of control of the aircraft.
Investigators identified evidence of arcing in wiring of the in-flight entertainment system network, but this did not trip the circuit breakers. The investigation was unable to confirm if this arc was the "lead event" that ignited the flammable covering on MPET insulation blankets that quickly spread across other flammable materials. The crew did not recognize that a fire had started and were not warned by instruments. Once they became aware of the fire, the uncertainty of the problem made it difficult to address. The rapid spread of the fire led to the failure of key display systems, and the crew were soon rendered unable to control the aircraft. Because he had no light by which to see his controls after the displays failed, the pilot was forced to steer the plane blindly; intentionally or not, the plane swerved off course and headed back out into the Atlantic. Recovered fragments of the plane show that the heat inside the cockpit became so great that the ceiling started to melt. The recovered standby attitude indicator and airspeed indicators showed that the aircraft struck the water at 300 knots (560 km/h, 348 mph) in a 20 degrees nose down and 110 degree bank attitude, or almost inverted. Death was instantaneous for all passengers and crew due to the impact forces and deceleration.
The TSB concluded that even if the crew had been aware of the nature of the problem immediately after detection of the initial odour, and had a commenced an approach as rapidly as possible, the developing fire related conditions in the cockpit would have made a safe landing at Halifax impossible.
The TSB made nine recommendations relating to changes in aircraft materials (testing, certification, inspection, and maintenance), electrical systems, and flight data capture, as both flight recorders had stopped when they lost power six minutes before impact. General recommendations were also made regarding improvements in checklists and in fire-detection and fire-fighting equipment and training. These recommendations have led to widespread changes in FAA standards, principally impacting wiring and fire hardening.
In September 2011, the CBC program The Fifth Estate reported allegations suggesting that an incendiary device might have been the cause of the crash. These claims came from a former RCMP officer who claims that suspicious levels of magnesium and other elements associated with arson were discovered in the wiring and that he was ordered to remove references to magnesium or a suspected bomb from his investigative notes. The CBC later reported that the presence of magnesium could be explained by the long exposure of the wires to seawater, but that the levels discovered were higher than would normally be expected.
Two memorials to those who died in the crash have been established by the Government of Nova Scotia. One is to the east of the crash site at The Whalesback, a promontory one kilometre (0.6 mile) north of Peggys Cove. The second is a more private, but much larger commemoration located west of the crash site near Bayswater Beach Provincial Park on the Aspotogan Peninsula in Bayswater. Here, the unidentified remains of the victims are interred. A fund was established to fund maintenance of the memorials and the government passed an act to recognize them. Various other charitable funds were also created, including one in the name of a young victim from Louisiana, Robert Martin Maillet, which provides money for children in need.
In September 1999 Swissair, Delta, and Boeing (who had acquired McDonnell Douglas through a merger in 1997) agreed to share liability for the accident and offered the families of the passengers financial compensation. The offer was rejected in favor of a $19.8 billion suit against Swissair and DuPont, the supplier of the Mylar insulation sheathing. A US federal court dismissed the claim in February 2002.
At the time of the accident, no other tri-jet airliner was in production aside from the McDonnell Douglas MD-11. Boeing, which had merged with McDonnell Douglas in 1997, still produced the MD-11 as a freighter; the last passenger version was delivered in 1998 to Sabena. The last MD-11 overall was delivered to Lufthansa Cargo in 2001, as a freighter.
After the crash, the flight route designator for Swissair's New York-Geneva route was changed to Flight 139, still using an MD-11. After Swissair's bankruptcy in 2002, the flight designator was changed again to Flight LX 023, now operated by an Airbus A330-300.
Since the crash, there have been many television documentaries on Flight 111, including the CBC's The Fifth Estate, "The Investigation of Swissair 111", PBS's NOVA "Aircrash", and episodes of disaster shows like History Channel's Disasters of the Century, Discovery Channel's Mayday, and National Geographic Channel's Seconds From Disaster. NOVA created a classroom activity kit for school teachers, using the crash as an example of an aircraft crash investigation.
In May 2007, the TSB released copies of the audio recordings of the air traffic control transmissions associated with the flight. The transcripts of these recordings had been released in 1998 (within days of the crash), but the TSB had refused to release the audio on privacy grounds. The TSB argued that under Canada's Access to Information Act and Privacy Act, the audio recordings constituted personal information and were thus not disclosable. Canada's Federal Court of Appeal rejected this argument in 2006 in a legal proceeding concerned with air traffic control recordings in four other air accidents. The Supreme Court of Canada did not grant leave to appeal that decision and consequently the TSB released a copy of the Swissair 111 air traffic control audio recordings to the Canadian Press, which had requested the recordings under the Access to Information Act. Several key minutes of the air traffic control audio can be found on the Toronto Star web site.
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- "Accident Synopsis 09021998". AirDisaster.com. Retrieved 12 October 2011.
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- Transportation Safety Board (2003), "In-Flight Fire Leading To Collision With Water", Aviation Investigation Report, A98H0003 - French version available here
- Butler, John Marshall (2001). Forensic DNA Typing: biology & technology behind STR markers. Academic Press, San Diego. ISBN 0-12-147951-X.
- Kimber, Stephen (1999). Flight 111:The Tragedy of the Swissair Crash. Seal Books, Toronto. ISBN 0-7704-2840-1.
- Wilkins, David; Murphey, Cecil (January 2003). United by Tragedy: A Father's Story. Pacific Press Publishing Association. ISBN 0-8163-1980-4.
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- Transportation Safety Board of Canada
- Detailed report about the crash on Austrian Wings (German, published on 2 September 2013)
- Swissair - Information about the accident of SR111 - Swissair (Archive)
- Swissair Flight 111 - Memorial Website
- Full Coverage:World News:Swissair Crash Investigation - Yahoo! News
- PlaneCrashInfo.Com - Swissair Flight 111 Entry
- The Investigation of Swissair 111 The Nature of Things Canadian Broadcasting Corporation (Flash movie)
- Esquire July 2000 report “The Long Fall of One-Eleven Heavy” highlighting the human side of the accident
- Lloyd's of London
- "Lloyd's statement regarding Swissair crash site license application." Friday 19 May 2000. (Archive)
- "Lloyd's statement regarding the Swissair crash site." Tuesday 23 May 2000. (Archive)
- Swissair Flight 111 - Memorial, Bayswater, Nova Scotia