Royal Aeronautical Society Flight Operations Group Meeting
Opening Remarks by
Transportation Safety Board of Canada
at the Royal Aeronautical Society Flight Operations Group Meeting
"Swissair 111: Where Do We Go from Here?"
October 22nd, 2008
Good afternoon. Thank you for the kind introduction. I am pleased to be here as a Member of the Transportation Safety Board of Canada (TSB) and to have the opportunity to speak to such a unique body dedicated to the entire aerospace community.
As a leader and provider of foresight, and given the diversity of disciplines it involves, the Royal Aeronautical Society is a key audience to speak to about how we can work together to improve aviation safety worldwide.
Today I want to talk to you about outstanding safety deficiencies uncovered in the TSB's investigation of the 1998 Swissair Flight 111 accident.
I will start by telling you what happened, about the TSB investigation and the recommendations made by the Board to mitigate the identified risks. I will then highlight the safety action taken since and mark the areas where more action is needed.
Finally, I will ask for your assistance in helping the Board achieve further progress on its Swissair recommendations worldwide in three specific areas.
Before I tell you about the Swissair accident, let me take a few minutes to talk about the Transportation Safety Board of Canada, or TSB.
We are an independent government organization with a mandate to advance transportation safety by conducting investigations into marine, rail, air and pipeline occurrences.
Each year, approximately 1,900 aviation occurrences are reported to the TSB. We conduct full investigations when there is potential to reduce risks to people, property or the environment and to advance safety.
The TSB doesn't wait until an investigation is complete to make important safety information public. When we identify a safety deficiency, we act quickly by communicating it to those who can make transportation safer. This allows industry and regulators to take timely safety action.
The really big safety payoff occurs when everyone agrees and safety deficiencies are quickly addressed.
The TSB periodically assesses the progress made on our recommendations.
Our legislation requires that the Canadian Minister of Transport advise the Board in writing of any action taken or proposed on a recommendation within 90 days of the date it was issued. The Board's assessment of that response hinges on how much has been planned or completed to make the system safer.
However, I must admit that in some cases we see limited progress.
Our recommendations inevitably call for changes. They may be implemented through amendments to regulations or changes to standards or organizational processes. Developing solutions and making changes can place significant demands on the pilots, the operators and regulators.
We naturally have the most influence with Canadian regulators and operators, but most aircraft in airline service are manufactured and type-certified in the US, or Europe. For example, when it comes to making changes to aircraft in Europe, it is the European Aviation Safety Agency's (EASA) responsibility to require or oversee these changes.
Now on to the Swissair accident.
As you may know, on September 2, 1998, Swissair Flight 111, a McDonnell-Douglas MD-11 departed New York City on a scheduled flight to Geneva, Switzerland, with 215 passengers and 14 crew members on board.
About 53 minutes later, while cruising at flight level 3-3-0, the crew smelled an abnormal odour in the cockpit. Their attention was drawn to the area behind and above them and they began to investigate the source - the air conditioning system. After further troubleshooting, they assessed there was definitely smoke and decided to divert to Halifax.
While the flight crew was preparing to land, they were unaware that a fire was spreading above the cockpit ceiling. Soon thereafter, the aircraft's FDR logged a rapid succession of system failures. The crew declared an emergency and an immediate need to land.
About one minute later, radio communications and radar contact were lost, and the flight recorders stopped functioning. About five and a half minutes later, the aircraft crashed into the ocean with the loss of all 229 souls on board.
The crew did what made sense to them at the time. As part of the TSB investigation, we pieced together the sequence of events and ran a number of detailed scenarios to determine what happened.
Based on the time available before the fire disabled the aircraft, there is no doubt that the crew COULD NOT have landed the plane safely.
The Swissair investigation took four and a half years to complete. It was the biggest and most complex safety investigation that the TSB has ever undertaken.
As with all our investigations, the TSB took the time necessary to conduct a thorough investigation of the safety deficiencies, causes and contributing factors to the accident. We did not lay any fault or blame. We looked beyond the immediate causes to find underlying failures in the system and make recommendations to prevent a similar occurrence in the future.
The need for a coordinated national and international effort was paramount, and the efforts of the many hardworking people from various countries, industries and regulatory authorities led to a world-class investigation, culminating in a comprehensive report that has helped to change the face of aviation safety.
The TSB made a total of 23 recommendations grouped in five main categories:
- on-board recorders,
- circuit breaker resetting procedures,
- the supplemental type certification process,
- material flammability, and
- in-flight firefighting.
For the purposes of today's presentation, I would like to highlight the Swissair recommendations in three specific safety areas: material flammability, on-board recordings and in-flight firefighting.
Last year, a Royal Aeronautical Society's paper authored by Captain John Cox took a comprehensive look at in-flight fires and provided some very thorough insight into mitigating risks. There is a great deal of commonality in the recommendations it made and the ones made in the TSB Swissair investigation report.
Our investigation found that a fire aboard Swissair 111 started when an electrical arc ignited insulation material made of metalized polyethylene terephthalate, or MPET.
This material was tested and certified according to flammability standards and regulations in place at the time the aircraft was manufactured.
The TSB issued eight recommendations associated with flammability during the Swissair investigation. These were mainly related to the adequacy of flammability testing standards and the flammability of the insulation materials themselves.
In response to our recommendations, regulators in Canada, the US and France almost immediately required the removal of MPET insulation from MANY aircraft, the first material to ignite in the Swissair accident.
Additionally, a more rigorous flammability test, the Radiant Panel Test, along with enhanced regulations and standards are now in place to validate insulation materials used in aircraft.
As for EASA, it issued Airworthiness Directives for the removal of MPET-covered insulation blankets in ATR 42's and ATR 72's.
Notwithstanding these successes, we believe more needs to be done.
We would like it if MPET was removed from ALL aircraft and we would like to know HOW the FAA's Alternative Means of Compliance will ensure insulation materials will not be flammable. We would also like to SEE more rigorous testing for ALL existing insulation materials.
Instead, regulators are relying on in-service performance to be the catalyst for further safety action.
In other words, a material has to fail before action is taken.
One such in-service failure did result in the detection of the flammability risk associated with the insulation material, AN-26. This material subsequently failed the new flammability test and was ordered removed from service.
But is that approach really good enough?
The Board subsequently recommended a review to quantify and mitigate the risks associated with all the types of materials that failed to meet the new requirements. To date, no positive action has been taken by regulators to address this deficiency.
Regarding material flammability, Captain Cox calls for improved maintenance procedures to ensure cleanliness and minimal contamination of wires and insulation materials. This recommendation is similar to one the Board made as part of our investigation into a cargo bay fire in May 2002 aboard an Air Canada Boeing 767.
As we mentioned before, it was likely an arcing wire from the in-flight entertainment system that ignited insulation materials aboard Swissair 111.
The in-flight entertainment system was installed in accordance with a Supplemental Type Certificate (STC). Its wiring was routed next to wires for critical aircraft systems such as instrumentation, and bypassed the Cabin Bus switch. This meant that if the Cabin Bus switch was turned off as part of a Smoke/Fume/Fire (SFF) checklist, those wires would still be live.
As such, the Board made a recommendation to improve the STC evaluation process - to ensure that equipment installed under STCs is properly integrated with type-certified procedures, such as emergency load-shedding that is part of SFF checklists. Captain Cox makes a similar recommendation, and calls for approving STC modifications that would follow the same process as that used to approve original type certificates.
Additionally, Transport Canada has been involved in a number of international initiatives related to wiring safety in aging aircraft. But action has not yet been taken to address our recommendation to establish a test regime that evaluates aircraft electrical wire failure characteristics under realistic operating conditions. Testing a single unpowered wire does not necessarily predict what will happen when that wire is bundled and carries an electrical load.
While standards exist for individual systems, additional action is needed to address potential risks posed by the interplay between systems.
In summary, our greatest concerns with regards to material flammability relate to wire testing, the procedures for supplemental type certificate approvals and the use of materials which would fail the new and more rigorous material flammability tests and standards.
In the transportation industry, aviation leads the way with requirements for FDRs and CVRs. With each investigation, including this one, we refine what data we need to figure out what happened.
The upshot is that the FAA now requires that any single electrical failure not disable both CVR and FDR. By 2012, the FAA will also require 2-hour CVRs and an independent power supply providing 10 more minutes of recording time.
Therefore, one can say that there has been progress for sure in this important area, and the FAA is leading the way.
However, we would like 2-hr CVRs to have an independent power supply and different recorders (such as a CVR and a FDR) to be powered by separate buses. This needs to become the international standard, not just the FAA's.
One other outstanding recommendation we feel strongly about is the installation of image recorders. These recorders will help investigators to better understand what went on in the cockpit and with the aircraft. The NTSB also made this recommendation.
That being said, the cockpit is a pilot's workplace and I understand why they would oppose greater surveillance. This resistance can only be overcome if the international community protects the confidentiality of all recordings. We must ensure they will not be released and will only be used to advance transportation safety.
The Board issued five recommendations on in-flight firefighting. We found that procedures weren't in place to direct crews to rapidly locate and eliminate the source of smoke in the aircraft, and to expedite preparations for an emergency landing.
In his paper, Captain Cox also took a very close look at the role crew actions and procedures played in the outcome of accidents involving in-flight fires, and made related recommendations to improve crew training and procedures.
The regulatory agencies readily concurred with the thrust of these recommendations, and acknowledged that significant deficiencies existed and took action to address them.
Here is what's been done to date:
Regulators now require that emergency procedures in aircraft flight manuals direct crews to prepare to land the aircraft without delay when smoke or fire is detected. As a result, crews routinely divert to land as soon as possible on the first hint of smoke in an aircraft.
IATA, with ALPA's participation, developed generic, industry-wide guidance material on more effective smoke and fire cockpit checklist procedures. Captain Cox strongly supports these improved procedures in his paper as an effective consensus approach among all stakeholders to reduce risks of in-flight fires.
As a result, various aircraft manufacturers and operators are making improvements to their Aircraft Flight Manuals and procedures. For example, Bombardier Aerospace amended its Aircraft Flight Manuals and emergency checklist procedures in January 2007, and I understand that Boeing has adopted this guidance material as have many operators using Boeing equipment. Airbus and some operators using their aircraft have adopted the guidance material as well.
TSB recommended that aircraft crews be prepared to respond immediately, effectively and in a coordinated manner to any in-flight fire, including inaccessible spaces such as attic areas.
Captain Cox also called for access ports to be installed in aircraft, or crew training in forcing interior panels to open to locate and fight fires in inaccessible areas.
Transport Canada and international regulators are working on improvements to current in-flight firefighting training and standards for crews.
We applaud the international community for taking these steps to improve safety in the event of in-flight fires. However, there is still work outstanding in this area. Overall, the Board's position is that a systematic approach towards in-flight fires must be developed to reduce residual risk.
This approach must:
- comprehensively identify fire zones,
- implement fire detection systems,
- provide fire-suppression systems and equipment,
- mandate checklist design criteria, and
- require appropriate training.
During an investigation, the TSB works with regulators, transportation companies, equipment manufacturers and service providers, to help us conduct a thorough investigation.
The Board makes recommendations to draw immediate attention to safety deficiencies that involve significant risk and that require immediate action.
The TSB recognizes the challenges regulators and industry face. We know that some recommendations can be addressed promptly, while others require more time and resources to completely mitigate the deficiency.
Ten years after the devastating Swissair accident, further action is still needed to mitigate the significant risks identified in 18 of 23 recommendations.
While TSB recommendations, for the most part, are addressed to the regulators, the responsibility for mitigating the safety risks belongs with some of you in this room today.
Therefore, I encourage you to follow TSB air investigations closely. When safety concerns are identified, ask: "What can I as a pilot, airline, or association do to lessen the identified risk?" If you are a pilot or an airline, you can make changes yourself. If you are an association or even an interested party, you can advocate for changes - you don't need to wait for the regulator to take action. Safety is good for everyone.
Sometimes when we are discussing the minutia of technical details, it is easy to lose sight of what this is all about. We must remember in the end, it's about preserving lives of crews and passengers. And, in this case, it is about the 229 men, women and children who lost their lives on September 2, 1998.
A fire initiated by an electrical arc, that set alight materials believed to be non flammable, and exacerbated by the failure of other material and systems. A fire that went undetected during those vital first few minutes, and that could not have been controlled by the firefighting capabilities of the aircraft and its crew. A fire that was only extinguished when the aircraft plunged into the sea off Peggy's Cove.
A call for action seems appropriate at this point. Although the three areas we talked about are all important, in our view the highest priorities should be:
- mandatory international adoption of the improved smoke, fire and fumes checklist templates; and
- adoption of a more systematic (or holistic) approach to in-flight fire fighting.
These two areas are pretty similar to RAS' and Captain Cox's views.
Lastly, we would like to see international harmonization of the protection accorded to cockpit voice and image recordings.
You know best who to speak to about these necessary changes, be it regulators, manufacturers or the airlines themselves.
The action taken by the aviation community in response to the Swissair recommendations has been substantial. We do acknowledge what regulators and industry have achieved to date.
We also recognize that the process can be slow and tortuous. It affects multiple facets of an organization.
But we cannot stop here or overlook the remaining safety deficiencies. They need to be addressed. And this must be an international effort.
I hope that you leave here today with a greater understanding of what has been accomplished since this tragedy 10 years ago, but also the importance of finishing the job to make aviation even safer.
I invite you to visit our website to look at the specific information on the Swissair accident.
Thank you for your attention.
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