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Swissair Flight 111

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Swissair Flight 111
Occurrence
DateSeptember 2 1998
SummaryIn-flight fire, subsequent instrument failure
SiteAtlantic Ocean near St. Margarets Bay, Nova Scotia
 Canada
Aircraft typeMcDonnell Douglas MD-11
Aircraft nameVaud
OperatorSwissair
RegistrationHB-IWF
Flight originJohn F. Kennedy International Airport
 United States
DestinationCointrin International Airport
Template:SWS
Passengers215
Crew14
Fatalities229
Survivors0

Swissair Flight 111 (SR-111, SWR-111) 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 September 2, 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 km from shore, roughly equidistant between the tiny fishing and tourist communities of Peggys Cove and Bayswater. All 229 people on board were killed.[1]

The resulting investigation by the Transportation Safety Board of Canada (TSB) took over four years and cost US$39 million (CAD$57 million).[2] Their main conclusion was that flammable material used in the aircraft's structure allowed a fire to spread beyond the control of the crew, resulting in the loss of control and crash of the aircraft.[3]

History

The aircraft and its crew

The aircraft, a McDonnell Douglas MD-11, serial number 48448, was manufactured in 1991 and Swissair was the only operator. The airframe had a total of 36,041 hours. The three engines were Pratt & Whitney 4462s. The cabin was configured with 241 seats (12 first-, 49 business-, and 180 economy-class). First- and business-class seats were equipped with an in-flight entertainment system.[4]

The standard crew of MD-11 is a flight crew of a captain and a first officer, and a cabin crew of a maître de cabine (M/C) and 11 flight attendants. All personnel were qualified, certified and trained in accordance with Swiss regulations, under the Joint Aviation Authorities (JAA).[5]

The flight

Flight SR-111 departed JFK at 20:18 (EDT) with 215 passengers, 2 pilots and 12 flight attendants en route to Geneva. At 22:10 Atlantic Time, cruising at FL330, or 33,000 feet (about 10,060 m), the flight crew Captain Urs Zimmermann and First Officer Stephan Loew, smelled an odour in the cockpit and determined it to be smoke in the air conditioning system. Four minutes later, the smoke was visible and the pilots began considering a diversion to a nearby airport for the purpose of a quick landing. At 22:14 AT the flight crew made a "pan-pan" radio call, indicating that an emergency exists but there is no immediate danger to the aircraft, and requested a diversion to Boston's Logan International Airport (300 nautical miles away), but was instead directed to the closer Halifax International Airport in Enfield, Nova Scotia, 66 nm (104 km) away. The crew then put on their oxygen masks and began descending.

At 22:19 AT the plane was 30 nautical miles away from Halifax airport, but required more time to descend from its current altitude of 21,000 feet. At 22:20 AT the crew informed ATC that it needed to dump fuel, and was subsequently diverted away from the airport. Dumping the fuel caused the power of the recirculating fans to shut off, causing the fire to spread back into the cockpit. At 22:24 AT, the crew declared an emergency. Aircraft systems, such as lighting, flight instruments, and the autopilot began to fail and as a result the crew slowly lost any means of successfully flying the aircraft. According to readings from seismographic recorders in Halifax and Moncton, the aircraft struck the ocean at 22:31 AT.[6] The crash location was approximately 44°24′33″N 63°58′25″W / 44.40917°N 63.97361°W / 44.40917; -63.97361, with 300 metres' uncertainty.[7]

Recovery and investigation

The aircraft broke apart 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.[8]

The initial focus of the recovery was on finding and identifying human remains, and finding the flight recorders, but this proved difficult as the force of impact (approximately 350 g[9]), and the environmental conditions, only allowed recovery along with wreckage.[10] Only one of the victims was visually identifiable. 147 were identified by fingerprint, dental records, and X-ray comparisons. The remaining 81 were identified through DNA tests.[11]

The cockpit voice recorder (CVR) and flight data recorder (FDR) were found by the submarine HMCS Okanagan using sonar to detect the underwater locator beacon signals, and quickly retrieved by Navy divers (the FDR on September 6 and the CVR on September 11, 1998). However, both had stopped recording at approximately 10,000 ft, six minutes before impact.

File:CCGV Hudson03.jpg
Canadian Coast Guard Ship Henry Hudson searches for Swissair Flight 111 debris

On October 2, 1998 the Transportation Safety Board of Canada (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 October 21, 27% of the wreckage was recovered.[12]

At this point in the investigation, the cause of the crash was generally believed to be due to 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 August 30, 2000, but the final report was not completed until 2003.[13]

The final phase of wreckage recovery by dredging ended 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.[8]

Examination

Cargo door and other debris recovered

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 a custom-built temporary structure on a discontinued runway at CFB Shearwater where it was assembled and inspected by over 350 investigators from multiple organizations such as TSB, NTSB, FAA, AAIB, Boeing, and Pratt & Whitney. [14][15]

As each piece of wreckage was brought in, it was carefully cleaned with freshwater, sorted, and weighed. The item was then placed in a specific area of the temporary structure 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 then weighed and moved to another hangar for long-term storage. If deemed significant to the investigation, the item was documented, photographed, and kept in the active examination hangar.[16] Particular attention was paid to any item showing heat damage, burns, or other unusual marks.

Cockpit

The front 10m (33 feet) 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.[17]

CVR and FDR

The cockpit voice recorder is a 1/4 inch recording tape, operating on a 30 minutes loop. It therefore only recorded for the last half hour of the flight, from 8:58:15.8 pm EDT until 9:25:41.[18][19] It also operated off the aircraft power, and stopped recording when the aircraft lost electrical power at 9:25 pm EDT (10:25 local time).[18]

TSB Findings

The investigation identified eleven causes and contributing factors of the crash in their 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.[20]

Arcing from wiring of the in-flight entertainment network did not trip the circuit breakers but ignited flammable covering on insulation blankets and 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's ability to control the aircraft was soon overcome. Because he had no light by which to see his controls after the displays failed, the pilot was forced to steer the plane blindly; as a result, 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 indicator showed that the aircraft struck the water at 300 knots in a 20 degrees nose down and 110 degree bank turn, or almost upside down [21]. Upon impact, in less than a second, the plane would have been crushed, killing all aboard almost instantly.

The TSB concluded that even if they had been aware of the nature of the problem, the rate of spread of the fire would have precluded a safe landing at Halifax even if an approach had begun as soon as the "pan-pan" was declared.

TSB Recommendations

The TSB made nine recommendations relating to changes in aircraft materials, electrical systems, and flight data capture. (Both flight recorders failed, along with main power, six minutes before impact.) General recommendations were also made regarding improvements in checklists and in fire-detection and fire-fighting equipment.

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 duration. The Transportation Safety Board team had to reconstruct the last six minutes of flight entirely from the physical evidence. The plane was broken into millions of small pieces by the impact, making this process time-consuming and tedious. The investigation became the longest (five years) and most expensive (57 million CAD) transport accident investigation in Canadian history.

Legacy

Bayswater, Nova Scotia memorial.

Two memorials to the victims have been established by the government of Nova Scotia. One is located east of the crash site at The Whalesback, a promontory 1 km north of Peggys Cove. The second memorial is a more private but much larger commemoration located west of the crash site near Bayswater Beach Provincial Park on the Aspotogan Peninsula. Here, the unidentified remains of the victims are interred.

In September 1999 Swissair and Boeing offered the families of the passengers full compensatory damages. This was rejected in favor of a $19.8 billion suit against Swissair and DuPont, the supplier of Mylar insulation sheathing. The claim was rejected in a US federal court in February 2002.[22]

A number of notable individuals died in this accident, including Jonathan Mann, former head of the WHO's AIDS program; Mann's wife, AIDS researcher Mary-Lou Clements-Mann; Pierce J. Gerety Jr., head of UNHCR for the Great Lakes Region of Africa, who was on a special mission for U.N. Secretary General Kofi Annan to the Congo to attempt to negotiate a peace accord with Laurent Kabila in an erupting regional war; and Joseph LaMotta, son of former boxing world champion Jake LaMotta, [23] [24] A number of works of art, including a piece by Pablo Picasso, were lost in the crash.

After the crash, the flight route designator for Swissair's New York-Geneva route was changed to Flight 139.

Since the crash there have been many television documentaries on Flight 111, including episodes of disaster shows like History Channel's Disasters of the Century, Discovery Channel's "MayDay" and National Geographic's Air Crash Investigation as well as PBS's NOVA.

In May 2007 the TSB released copies of the audio recordings of the air traffic control transmissions associated with the flight. One of the pilots was reported to have spoken in a heavy Swiss-German accent.[25][26] 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. However, 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.[27] 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 Canadian Press, which had requested them under the Access to Information Act.[28] Several key minutes of the air traffic control audio can be found on the Toronto Star web site.[29]

Notes

  1. ^ AirDisaster.com database
  2. ^ http://www.pbs.org/wgbh/nova/aircrash/dissection.html PBS.org "Nova: Crash of Flight 111" Referenced August 5, 2006
  3. ^ TSB Report Conclusions 3.1, page 253, "Findings as to Causes and Contributing Factors", paragraph 1
  4. ^ TSB 1.6, page 9, "Aircraft Information"
  5. ^ TSB 1.5, pages 5-7, "Personnel Information"
  6. ^ TSB 1.1, pages 1-3, "History of the Flight", paragraph 13
  7. ^ http://www.tsb.gc.ca/en/media/emergency/background/location_debris_field.asp
  8. ^ a b TSB 1.12, page 77, "Wreckage Recovery"
  9. ^ TSB 1.13.3, "Injury Patterns"
  10. ^ TSB 1.13, page 103-105, "Recovery of Occupants"
  11. ^ Butler, page 264, "DNA Testing in High Profile Cases"
  12. ^ http://www.tsb.gc.ca/en/media/fact_sheets/A98H0003/chronology_a98h0003.asp TSB
  13. ^ Template:Harvard reference
  14. ^ TSB 1.12.2.1, page 80, "Aircraft Wreckage Examination
  15. ^ TSB Supporting Technical Information STI-098
  16. ^ TSB 1.19.1, page 197-198, "Exhibit Tracking Process
  17. ^ TSB 1.19.3, page 199, "Partial Aircraft Reconstruction
  18. ^ a b TSB 1.11, pages 73-74, "Flight Recorders
  19. ^ 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 appear on numerous external websites, including Aviation Safety Network - ATC transcript Swissair Flight 111 - 02 SEP 1998 (accessed November 27 2006). The air traffic control audio was released in May 2007; several key minutes of it are available at the Toronto Star (accessed May 25 2007).
  20. ^ TSB 3.1, page 253, "Findings as to Causes and Contributing Factors
  21. ^ TSB 1.12.12, page 103, "Aircraft Attitude and Airspeed at the Time of Impact
  22. ^ Rapoport Law Offices Over $13 Million for Victims of Swissair Disaster. Retrieved on November 24, 2006.
  23. ^ Chebucto Community Net Passengers and Crew Members, Swiss Air Flight 111: 2 September 1998. Retrieved on November 24, 2006.
  24. ^ CNN.com Names of Swissair crash victims. Retrieved on November 24, 2006.
  25. ^ Dean Beeby. "Swissair recordings revive horrifying drama of deadly 1998 tragedy". Canadian Press. Retrieved 2007-05-25.
  26. ^ "Swissair crash recordings revive drama of one of Canada's worst aviation disasters". 2007-05-22. Retrieved 2007-05-25. {{cite web}}: Check date values in: |date= (help)
  27. ^ Canada (Information Commissioner) v. Canada (Transportation Accident Investigation and Safety Board), 2006 FCA 157
  28. ^ Dean Beeby (2007-05-22). "Doomed flight's tapes released". Toronto Star. Retrieved 2007-05-25. {{cite web}}: Check date values in: |date= (help)
  29. ^ "Canadian Press video of last minutes of Swissair flight 111 (QuickTime format)". Retrieved 2007-05-25.

References

  • Template:Harvard reference
  • 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.
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