Speeches

Notes for Remarks by
The Hon. Benoît Bouchard
Chairperson of the Transportation Safety Board of Canada
at the release of recommendations on
materials flammability standards
related to the crash of Swissair Flight 111
National Press Theatre
Ottawa, Ontario
28 August 2001

Thank you, ladies and gentlemen, for coming here this morning. In this, as in all investigations, the Transportation Safety Board is grateful to the media for helping us get our safety messages out to the industry, the regulators and the travelling public.

As many of you know, on September 2nd, nearly three years ago, 229 people lost their lives when Swissair Flight 111 crashed into the ocean near Peggy’s Cove, Nova Scotia. It was one of the worst aviation tragedies the world has ever seen. And for us at the TSB, the investigation into what happened on that fateful day has been far and away the most complex and challenging we have ever faced.

Today we wish to draw attention to a number of safety deficiencies related to flammability—the tendency of certain materials used in the construction of aircraft to cause or sustain an in-flight fire.

Our purpose in issuing these recommendations now is to enhance the safety of the travelling public as quickly as possible, as we have done on previous occasions during this lengthy investigation. We want everyone to know about potential safety deficiencies as soon as we learn about them, so that public safety is not compromised while we continue our work to evaluate what happened to Swissair Flight 111.

With me today is Vic Gerden, the Investigator-in-Charge. He will be able to provide you with all the technical details you need to understand this latest round of recommendations.

But first, allow me to share with you a bit of the context.

The Transportation Safety Board is an independent agency that reports directly to Parliament. Our role is to examine all the factors that may have played a role in accidents or near-accidents, whether in the air, on water, or along Canada’s railways and pipelines.

We’re not just looking for a single cause, because there is seldom just one. Accidents, especially catastrophic ones, are always intricate webs of circumstances—a giant puzzle of things that can and do go wrong.

In the case of Flight 111, we faced a puzzle of astounding magnitude. With the cooperative effort of many people, over two million pieces of the plane and its components have been brought up from the ocean floor, and examined by our investigative team.

It is a painstaking task. We know, for instance, that the in-flight fire could have been ignited by an electrical arc from a wire , but here’s a sobering fact: an aircraft of this type contains about 250 kilometres of electrical wire, and it would take only a few millimetres of damage to potentially cause a wire to fail and spark a flame.

And so, the investigation takes time. Three years so far, and still portions of the investigation are ongoing.

But safety cannot wait. Whenever there has been something to say, we have said it. Over the past three years, we have issued three sets of recommendations, and a number of safety communications on issues ranging from aircraft wiring , to flight recorders, thermal acoustic insulation, map lights, and in-flight firefighting equipment and emergency procedures. In your package of background material, you will find an abbreviated summary of safety action already taken in response to previous TSB recommendations, safety advisories, and so on.

In addition, Vic and his team have developed excellent relationships with safety authorities in the United States, Europe and elsewhere, to make sure that the process of correcting safety deficiencies begins as soon as we identify them.

To put it bluntly, our goal throughout this process has been to scoop our own final report. Our ideal would be to have the regulators, the aircraft manufacturers and the air carriers all working on the solutions long before we come out with our final and formal account of the investigation.

And so, today again, we are here to release three further safety recommendations, so that appropriate actions can be taken to enhance public safety.

Let me give you a brief overview of today’s recommendations.

We have said before that a fire in the cockpit ceiling contributed to the crash of Flight 111. But a fire has many parts. It needs an ignition source. It needs material to burn. It needs a flow of fresh air to feed it. Each of these elements needs to be addressed, and today’s recommendations speak to several of them.

Our first recommendation deals with the flammability standards for materials used in the construction of aircraft. Over the years, manufacturers have become very good at making sure that seats and interior cabin panels burn as little as possible in the event of a crash.

But it is also true that in behind those panels—often in places where there are few, if any, defenses in terms of fire detection and suppression—you can find various materials that can sustain a fire. And these materials don’t just burn; they can also emit toxic gases and excessive amounts of smoke.

That’s why we are recommending a toughening of the flammability standards for all materials used in any part of the aircraft, including the cabin, the cockpit, and all the hidden areas—not just walls and seat cushions.

Our second recommendation relates to electrical wiring, which, as I said before, has not been ruled out as a factor in this accident.

We believe that the existing certification procedures are inadequate, and so we are recommending a far more stringent certification test regime for electrical wires—one that takes into account the various ways in which wires may fail— and more realistic testing, that is, test conditions very similar to what would be encountered in an actual airplane.

Our third recommendation addresses situations that can aggravate a fire already in progress—potentially turning a minor scare into a full-blown tragedy.

We find, for instance, that the system that delivers cockpit oxygen in the event of a loss of air pressure is tested to make sure it works properly in those conditions. Essentially, the system is certified to work for the purpose intended.

But what role does that system play if one of its components fails as a result of an in-flight fire? Does it end up delivering a fresh supply of air or oxygen to the fire, thereby making an otherwise manageable fire burn out of control?

We believe that all systems—oxygen, air conditioning, and so on—should be evaluated in terms of their impact on an in-flight fire, if the system were to fail while a fire is already in progress. In the event that they could worsen such a fire, we feel that such systems ought to be redesigned to make them safer.

That, then, is the basic outline of today’s recommendations. I would now ask Vic Gerden to provide you with some of the technical background.

-----------------Vic Gerden technical presentation--------------

Thank you, Vic.

Before I close, I would just like to add a few personal remarks.

This is my last news conference before I retire from the Transportation Safety Board. Having been responsible for the creation of the TSB when I was Transport Minister back in 1989, and having served as its chairman for the past five years, I would like to take this opportunity to reflect on the many safety improvements that are occurring in the industry.

Whether as a result of our work on this particular accident, or on any of the hundreds of investigations that have been completed by the TSB for other occurrences such as the fatal derailment of a passenger train in Thamesville, Ontario, or the tragic sinking of the "TRUE NORTH II" in Georgian Bay, I can point with pride to significant progress towards enhancing the safety of the travelling public.

On the whole, the world of aviation is a very safe one. Travellers spend millions of hours a year in the air, and they are right in believing that their first concern should be whether their luggage will arrive on time, at the same destination.

To the extent that something ever does go wrong, we try to find out what happened and why, so that it doesn’t happen again.

To the extent that we can anticipate what might go wrong, we also try to get the industry to make changes that will head off potential tragedies.

True, we do not live in a risk-free world, and there will always be some risk associated with flying. I can say, however, that the transportation industry and the regulators have been working with us to make air transportation safer with each passing year.

And the reason for this excellent collaboration is the TSB’s first-rate reputation around the globe. As much as we, as Canadians, tend to be modest, we ought to recognize that the world admires our independence and integrity, our exacting standards, and the precision and technical expertise of people like Mr. Gerden and our investigative teams.

When we start on an investigation, people trust us to dig and dig, until we have gathered all the facts. And then to share what we have learned, without fear of pressure or reprisals. We are agents of no one but the Canadian people and, through them, the world’s travelling public.

And so, as I leave the TSB, it is with a mixture of pride and confidence. I don’t know who will replace me in this job, but I can tell you one thing: the Transportation Safety Board’s work on Flight 111, and all the other occurrences, will carry on without interruption, in the same professional manner as always.

The families of the Flight 111 victims count on it. You and I and all Canadian travellers count on it. The world expects nothing less.

Thank you again for coming here today.